Priorities in care

 

 

Trauma kills millions and causes 12% of global morbidity.

 

 

Aetiology (in order of incidence)

 

RTI

Self inflicted violence

Interpersonal violence

Drowning

War

Falls

Poisoning

Fires

 

 

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.

 

 

 

 

Emergency management

 

Deal with conditions or injuries interfering with vital physiological function. This will normally be,

Airway

Breathing

Circulation

Haemorrhage

Head injury

Fractures

Other damage

 

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

A          Airway

C          Cervical spinal cord

B          Breathing

C          Circulation

 

 

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).

Auscultation.

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.         

Pulse oximetery.

 

 

 

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 37–40oC, 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.

 

Lateralizing signs.

 

Spinal cord injury and level.

 

Beware a patient may ‘talk and die’.

 

Low GCs then check oxygenation, ventilation and perfusion

 

 

 

 

 

 

 

 

Exposure

 

Usually cut off clothes.

 

Prevent hypothermia.

 

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.

 

 

 

 

Pitfalls

 

Elderly

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

 

Children

Brilliant compensators.  Deterioration is therefore precipitous and catastrophic.

 

Athletes

Also excellent compensators.

Have lower normal parameters

 

Constant re-evaluation all patients

 

 

 

 

 

Secondary- survey

 

Takes place after the primary when normal vital functions are present.

 

 

 

SAMPLE assessment

 

S             Signs and symptoms

 

A             Allergies

 

M             Medicines

 

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.

 

Keep records.

 

Consent when possible, if not ASAP.

 

Forensic evidence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Thoracic trauma

 

 

Simple pneumothorax,

 

Presentation

Reduced breath sounds.

Hyper-resonant percussion.

Hypoxia.

Hypercarbia.

CXR

 

Causes

Penetration, open, sucking chest wound

Blunt trauma, lung laceration

Especially with IPPV

 

Management

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.

 

 

Tension pneumothorax

 

A clinical diagnosis reflecting air, under pressure, in the pleural space. Treatment can not be delayed for radiographic confirmation.

 

Chest pain

Air hunger

Respiratory distress

Tachycardia

Hypotension

Tracheal deviation

Unilateral absence of breath sounds

Hyper-resonance

Neck vein distension

Eventually, cyanosis

 

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.

 

 

 

 

Haemothorax

 

Massive is over 1500 mls of blood loss.

Haemothorax < 1500 mls

 

Massive haemothorax

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

 

 

Flail chest

 

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

Paradoxical movement.

Hypoxia.

 

Ensure adequate ventilation

 

Humidified oxygen

Administer fluids adequately but judiciously

Analgesia (local or systemic) to improve ventilation

CPAP

Intubation and ventilation

 

 

 

Pulmonary contusion

 

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

 

 

 

Cardiac tamponade

 

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

 

Echocardiogram

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdominal injuries

 

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

 

Investigations

Baseline bloods and cross match

Pass a Nasogastric tube and aspirate

Pass a urinary catheter

Radiographs of chest, abdomen, pelvis

FAST scan

PR for the presence of blood

Observe for bluish discoloration, asymmetry, abrasions, contusions

Abdominal girth measurements are not useful                

 

Indications for laparotomy

Unexplained shock

Rigid silent abdomen

Evisceration

Radiographic evidence of free intraperitoneal gas

Radiographic evidence of ruptured diaphragm

All gunshot wounds

Positive result from ultrasound scan

 

Management principles

Obtain history.

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                     

Reassure

 

Penetrating injuries

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

Pre-op preparation

 

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

•     hypovolaemia                    

•     pain, worse on movement   

•     rebound tenderness

•     guarding    

•     diminished bowel sounds and activity

 

 

 

 

 

Renal injuries

 

Aetiology

Sports injuries 55%

RTAs 25%

Domestic and industrial accidents 5%

Assault 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

 

Classification

Minor 85% – contusions, superficial lacerations, capsule intact

Major  10% – deep lacerations, capsule tears

Critical 5% – renal fragmentation, vessel involvement

 

Clinical features

Pain

Haematuria

Ureteric colic from blood clots

Local rigidity of anterior abdominal wall

 

Management

Strict bed rest

Keep warm

Analgesia

Prophylactic antibiotics

Local and systemic observations

Ambulation only after haematuria is cleared

Surgery for more serious cases

One year follow up for complications

 

 

Pelvic injuries

Always check for pelvic fractures.

Apply pelvic girdle to close the pelvis.

Examine the urethral meatus in men, blood indicates urethral injury.

 

 

Urinary bladder

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.

 

 

Crush injuries

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).

Renal hypoperfusion                            

Acute renal failure

Monitor / restrict fluids and potassium.

 

 

Wounds

Objectives - control haemorrhage, avoid complications, promote healing, minimise scarring and prevent deformity.

Remove any contamination, foreign bodies

Dressings

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

 

Simple triage

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.

Decide -  Scoop and dash or stabilization at the scene

 

Advanced triage

Deciding a casualty should not receive advanced care because they are unlikely to survive. Change to palliative care.

 

 

Group work

 

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.