Priorities in care
Trauma kills millions and causes 12% of global morbidity.
Aetiology (in order of incidence)
Self inflicted violence
Trimodal death distribution
First peak, immediate deaths, seconds to minutes, apnoea, heart and large vessel injury, brain and high cord injuries.
Second peak, early deaths, minutes to hours, intracranial haematoma, haemopneumothorax, ruptured spleen, laceratin of liver, pelvic fractures, multiple injuries or fractures causing blood loss. Importance of the Golden Hour.
Third peak, days to weeks, late deaths, sepsis, multiple organ dysfunction.
Deal with conditions or injuries interfering with vital physiological function. This will normally be,
Place a number to show the order of priority you would give to each of the following features in a newly admitted unconscious patient.
Fractured wrist with bony displacement
Blood oozing from a head wound
Unconscious patient starts to vomit
Compound Fracture of the Fibula
Rapidly cyanosing patient
Unequal pupils are observed
Tachycardia with reduced BP
Patient smells of alcohol
Severe nose bleed
Paramedics often use ACBC
C Cervical spinal cord
A and E units use ABCDE which is the Primary Survey
A Airway and cervical spine protection.
B Breathing and ventilation.
C Circulation and haemorrhage control.
D Disability; neurological status, AVPU, GCS.
E Exposure; completely undress the patient but prevent hypothermia, detect and monitor other injuries, consider further care, promote comfort.
During the primary survey, life threatening conditions are identified and managed simultaneously. Major problems should be corrected as they are identified.
A with C spine protection
Assess patency of airway, look listen feel.
Consider, opening airway, chin lift, jaw thrust, airway adjuncts.
Assume C spine damage until proved otherwise, use trinity of protection.
Identify, airway obstruction, foreign material, presence of vomit, stridor, less than 8 intubate.
A definitive airway should be established if there is any doubt that a patient can maintain their own.
Consider gastric catheters, with suction, to decompress the stomach, reducing risk of aspiration.
Breathing and ventilation
Expose the chest, observe bilateral movements (excursion).
Visual inspection and palpation.
Identify, pheumothorax, tension pneumothorax, open pneumothorax, rib fractures, flail segments, pulmonary contusion, haemothorax.
All injured patients should be given high concentrations of oxygen.
Surgical airway should be established if intubation is contraindicated or impossible.
Tension pneumothorax should be decompressed.
Circulation and haemorrhage control
Definitive control of haemorrhage, with intravenous replacement of intravascular volume.
On the floor and four more.
Assess blood volume and cardiac output.
Assume hypotension is caused by hypovolaemia.
Level of consciousness, may or may not be reduced in hypovolaemia.
Skin colour, ashen, grey facial skin with white extremities.
Pulse, peripheral and central pulses, rate, rhythm, volume.
When the blood pressure is low the peripheral pulses go.
Short and fat I.V. cannula.
Give crystalloids, titrated with response.
3 for 1 rule.
For every big bleed, 3 for 1 you will need.
All infusions should be warmed to 3740oC, a microwave may be used to heat crystalloids, but not blood.
Consider other causes of hypotension in non-responders to fluids.
ECG in all trauma
Consider urinary catheter unless urethral injury present.
Disability; neurological status
Level of consciousness.
Pupillary size and reaction.
Spinal cord injury and level.
Beware a patient may talk and die.
Low GCs then check oxygenation, ventilation and perfusion
Usually cut off clothes.
Warm IVIs and blood.
Protect obvious wounds with dressings.
Consider other medical problems, e.g. hypoglycaemia.
Relieve pain as soon as possible without drugs.
Treat with analgesia as soon as diagnosis is made.
May have limited ability to increase heart rate in response to haemorrhage
May be on anticoagulants for other conditions
Other medications or medical conditions may be present
Brilliant compensators. Deterioration is therefore precipitous and catastrophic.
Also excellent compensators.
Have lower normal parameters
Constant re-evaluation all patients
Takes place after the primary when normal vital functions are present.
S Signs and symptoms
P Past medical history / Pregnancy
L Last meal
E Events / Environment leading to the incident
Physical examination, heat to toe.
Blunt, penetrating, thermal injuries
Head, face, C spine and neck, chest, abdomen, perineum, rectum, vagina, MSK, complete neurological survey.
Log roll, 3 over, 3 under.
X-rays as indicated by examination
Further investigations, bloods
Collect history of the incident, including details of the trauma, blunt or penetrating trauma, thermal injuries, unconsciousness, chemicals, hazardous environments.
Consent when possible, if not ASAP.
Reduced breath sounds.
Penetration, open, sucking chest wound
Blunt trauma, lung laceration
Especially with IPPV
Overlapping dressing secured on 3 sides to provide a flutter type valve.
An occlusive dressing may lead to tension effects.
Insert chest drain, remote from the wound.
Re X ray
High index of suspicion for tension effects
Surgical closure of the wound.
A clinical diagnosis reflecting air, under pressure, in the pleural space. Treatment can not be delayed for radiographic confirmation.
Unilateral absence of breath sounds
Neck vein distension
Needle thoracentesis, large bore cannula, midclavicular line, second intercostal space. Then chest drain, fourth or fifth intercostal space (usually at nipple level) anterior to midaxillary line.
Massive is over 1500 mls of blood loss.
Haemothorax < 1500 mls
Ventilations are inhibited, hypoxia
Systemic or hilar vessels
Shock associated with reduced breath sounds and dullness to percussion
Chest drain and intravenous fluids, crystalloids followed by type specific blood.
Collect blood for autotransfusion.
Preoperative care for thoracotomy for massive
Hypoxia is largely caused by underlying lung injury causing pulmonary contusion.
Two or more ribs fractured in two or more places.
Pain causing restricted chest wall movement with subsequent hypoxia
Ensure adequate ventilation
Administer fluids adequately but judiciously
Analgesia (local or systemic) to improve ventilation
Intubation and ventilation
The most common, potentially lethal chest injury.
Not always associated with rib fractures.
Respiratory failure may develop slowly, over time.
SaO2 <90% or PaO2 less than 8.6 KPa on room air may require intubation and ventilation
Pericardium is a fixed fibrous structure
A cause of non-response to fluids
Usually caused by penetrating injuries, but may also be caused by blunt trauma.
Venous pressure elevation
Reduced arterial pressure
Muffled heart sounds
Non-responders to fluids
Focused assessment sonogram in trauma (FAST scan).
Pericardiocentesis gives diagnosis and relieves immediate symptoms
Blunt heart injury
Blunt trauma rapid deceleration a may lead to myocardial injury and dysrhythmias. Hypoxia and acidosis enhance this possibility.
PEA may present in cardiac tamponade, tension pneumothorax, profound hypovolaemia and cardiac rupture.
Look - examine the entire body surface from the 5th rib down
Feel abdominal rigidity indicates visceral injury
Pain on percussion and coughing may indicate intraperitoneal injury
Baseline bloods and cross match
Pass a Nasogastric tube and aspirate
Pass a urinary catheter
Radiographs of chest, abdomen, pelvis
PR for the presence of blood
Observe for bluish discoloration, asymmetry, abrasions, contusions
Abdominal girth measurements are not useful
Indications for laparotomy
Rigid silent abdomen
Radiographic evidence of free intraperitoneal gas
Radiographic evidence of ruptured diaphragm
All gunshot wounds
Positive result from ultrasound scan
Objectives - control of bleeding, maintain blood volume, prevention of contamination, prepare for surgery.
Remove clothing from whole area
Constantly assess primary survey
Keep emergency equipment to hand
Nurse still to prevent any clot displacement over bleeding vessels
Keep patient flat and comfortable
Keep warm, warmed IVIs
Nil by mouth, prevents increased peristalsis and vomiting
Avoid analgesic before diagnosis
Stab wounds 30% involve visceral injury
Bullet wounds 80-90% involve visceral injury
Control external bleeding
Do not try to remove implanted objects
Do not replace abdominal contents after evisceration injury
Cover and keep moist abdominal viscera
Prevent infection - anaerobic bacteria, tetanus
Blunt abdominal trauma
Seat belt injuries, e.g. avulsion (tearing) of small bowel or mesentery
May have few outward signs
Delayed complications possible, liver, spleen, pancreas, kidneys
Signs and symptoms of organ damage
pain, worse on movement
diminished bowel sounds and activity
Sports injuries 55%
Domestic and industrial accidents 5%
90% of renal injuries are blunt
Renal penetration occurs in 7% of patients with abdominal stab injuries
Major renal vessels or ureter may tear due to deceleration
Minor 85% contusions, superficial lacerations, capsule intact
Major 10% deep lacerations, capsule tears
Critical 5% renal fragmentation, vessel involvement
Ureteric colic from blood clots
Local rigidity of anterior abdominal wall
Strict bed rest
Local and systemic observations
Ambulation only after haematuria is cleared
Surgery for more serious cases
One year follow up for complications
Always check for pelvic fractures.
Apply pelvic girdle to close the pelvis.
Examine the urethral meatus in men, blood indicates urethral injury.
May be ruptured or perforated by pelvic fractures.
Full bladders are more likely to rupture or may shear off at the urethra.
May present with lower abdominal peritonism and inability to pass urine.
Loss of circulating blood volume into wound site, inflammation.
Paralysis of part, swollen, tense, hard.
Rhabdomyolysis - myoglobinuria, (dark brown urine, positive for blood, but with no cells).
Acute renal failure
Monitor / restrict fluids and potassium.
Objectives - control haemorrhage, avoid complications, promote healing, minimise scarring and prevent deformity.
Remove any contamination, foreign bodies
Prevent Infection - tetanus, antibiotics, post exposure prophylaxis.
Clean area round the wound, remove hair.
Wound Closure, (when clean), primary and delayed primary closures or secondary healing.
Family following a patients death
Communicate in private
Talk to family together with Doctor
Reassure everything possible was done
Allow family to talk about patient and ventilate feelings
Avoid unnecessary information eg. re. alcohol or drugs
Avoid sedating family - this masks or delays the grieving process, so making depression more likely
Allow family to view and spend time with the body
Triage and care priorities
Scene of mass casualties, started before transportation becomes available.
Dead - Black tag, those who are pronounced as such by a medically qualified person or paramedic who is legally qualified to pronounce death.
Immediate - Red tag, probably lying quietly and not screaming. The Golden Hour.
Urgent - Yellow tag, patients who can wait for a short time before transport to a treatment facility.
Delayed - Green tag, patients who can be delayed before transport from the scene.
Deciding a casualty should not receive advanced care because they are unlikely to survive. Change to palliative care.
All of these patients need your assessment in deciding what priorities of care are required. In each of the following identify:
1. Differential diagnosis.
2. Further observations, examination, tests or diagnostic procedures.
3. How the condition may develop without interventions, including specific complications.
4. Outline the priorities and management strategy required.
Harry, a 58 year old lorry driver who has been admitted to A and E with crushing central chest pain. He has no ECG changes.
Joan, a 37 year old hairdresser, has gone to her practice nurse complaining of pain in her left calf. There is no swelling.
Barry, a 16 pupil, has rang NHS direct after suffering asthmatic symptoms in the early morning. Unusually, he is not responding to his prescribed inhalers.
Anne is a 4 month old baby who has been unwell for the past 6 hours. She now has a fever. Her mother has rang her health visitor to express her concern.
Grace is a 19 year old university student. She rang you as an old school friend to ask for advice. She had felt unwell for the past 4 hours and has a headache. She does not like looking into a light but has no neck stiffness or rash.
Allan, a 24 year old mechanic, has arrived in A and E after eating a chicken sandwich from his mates bate box. He now has tingling in his mouth and his lips are a little swollen.
Alison, a 24 year old mother of two, has been admitted to A and E after falling off her scooter, her left leg is now shorter than her right, there is some local swelling and significant pain.
Barry, a 44 year old teacher, has been complaining of increased levels of pain the day after an internal fixation of a fractured tibia, he is very reluctant to move or stretch his affected leg. The circulation to his toes is normal.
Betty, a 22 year old single mum, has suffered a sudden drop in GCS an hour after being admitted to your acute admissions ward. She had recently fallen off a ladder and hit the side of her head, in the area of the parietal bone.
Janet, a 12 year old schoolgirl, has been unwell for the past 12 hours, her temperature in only 37.4`C but she is now complaining of a pain around her umbilicus.