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Trauma primary and secondary survay abdo and thoracic injuries lecture -.ppt
- 1. الرحيم الرحمن اهللبسم الرحيم الرحمن اهلل بسم APPROACH TO TRAUMA APPROACH TO TRAUMA ( (PRIMARY AND SECONDARY SURVEY PRIMARY AND SECONDARY SURVEY) ) HAMED RASHAD Professor of Surgery Banha Faculty of Medicine Egypt
- 2. Objectives Objectives Demonstrate conceptsof primary and Demonstrate concepts of primary and secondary patient assessment secondary patient assessment Establish management priorities in trauma Establish management priorities in trauma situations situations Initiate primary and secondary management Initiate primary and secondary management as necessary as necessary Arrange appropriate disposition Arrange appropriate disposition
- 3. Trauma Trauma Epidemiology Epidemiology – Leadingcause of death in the first 4 decades Leading cause of death in the first 4 decades – 150,000 deaths annually in the US 150,000 deaths annually in the US – Permanent disability 3 times the mortality rate Permanent disability 3 times the mortality rate – Trauma related dollar costs exceed $400 billion Trauma related dollar costs exceed $400 billion annually annually
- 4. Why ATLS? Why ATLS? Trimodal death distribution Trimodal death distribution – First peak instantly (brain, heart, large vessel First peak instantly (brain, heart, large vessel injury) injury) – Second peak minutes to hours Second peak minutes to hours – Third peak days to weeks (sepsis, MSOF) Third peak days to weeks (sepsis, MSOF)
- 5. Why ATLS? Why ATLS? ATLSfocuses on the second peak…..Deaths from: ATLS focuses on the second peak…..Deaths from: TBI, Epidurals, Subdurals, IPH… TBI, Epidurals, Subdurals, IPH… Basilar skull fractures, orbital fractures, NEO Basilar skull fractures, orbital fractures, NEO complex injury… complex injury… Penetrating neck injuries… Penetrating neck injuries… Spinal cord syndromes… Spinal cord syndromes…
- 6. Why ATLS? Why ATLS? ATLSfocuses on the second peak…..Deaths from: ATLS focuses on the second peak…..Deaths from: Cardiac tamponade, tension pneumothorax, massive hemothorax, Cardiac tamponade, tension pneumothorax, massive hemothorax, esophageal injury, diaphragmatic herniation, flail chest, sucking esophageal injury, diaphragmatic herniation, flail chest, sucking chest wounds, pulmonary contusion, tracheobronchial injuries, chest wounds, pulmonary contusion, tracheobronchial injuries, penetrating heart injury, aortic arch injuries … penetrating heart injury, aortic arch injuries … Liver laceration, splenic ruptures, pancreatico-duodenal injuries, Liver laceration, splenic ruptures, pancreatico-duodenal injuries, retroperitoneal injuries retroperitoneal injuries Bladder rupture, renal contusion, renal laceration, urethral Bladder rupture, renal contusion, renal laceration, urethral injury… injury… Pelvic fractures, femur fractures, humerus Pelvic fractures, femur fractures, humerus fractures… fractures… You get the point You get the point
- 7. Concepts of ATLS Conceptsof ATLS Treat the greatest threat to life first Treat the greatest threat to life first The lack of a definitive diagnosis should The lack of a definitive diagnosis should never impede the application of an never impede the application of an indicated treatment indicated treatment A detailed history is not essential to begin A detailed history is not essential to begin the evaluation the evaluation “ “ABCDE ABCDE” approach ” approach
- 8. Initial Assessment and InitialAssessment and Management Management An effective trauma system needs the An effective trauma system needs the teamwork of EMS, emergency medicine, teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialists trauma surgery, and surgery subspecialists Trauma roles Trauma roles – Trauma captain Trauma captain – Interventionalists Interventionalists – Nurses Nurses – Recorder Recorder
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- 10. Primary Survey Primary Survey Patients are assessed and treatment Patients are assessed and treatment priorities established based on their injuries, priorities established based on their injuries, vital signs, and injury mechanisms vital signs, and injury mechanisms ABCDEs of trauma care ABCDEs of trauma care – A A Airway and c-spine protection Airway and c-spine protection – B B Breathing and ventilation Breathing and ventilation – C C Circulation with hemorrhage control Circulation with hemorrhage control – D D Disability/Neurologic status Disability/Neurologic status – E E Exposure/Environmental control Exposure/Environmental control
- 11. Airway Airway How do weevaluate the airway? How do we evaluate the airway?
- 12. A- Airway A- Airway Airway should be assessed for patency Airway should be assessed for patency – Is the patient able to communicate verbally? Is the patient able to communicate verbally? – Inspect for any foreign bodies Inspect for any foreign bodies – Examine for stridor, hoarseness, gurgling, pooled Examine for stridor, hoarseness, gurgling, pooled secrecretions or blood secrecretions or blood Assume c-spine injury in patients with Assume c-spine injury in patients with multisystem trauma multisystem trauma – C-spine clearance is both clinical and radiographic C-spine clearance is both clinical and radiographic – C-collar should remain in place until patient can C-collar should remain in place until patient can cooperate with clinical exam cooperate with clinical exam
- 13. Airway Interventions Airway Interventions Supplemental oxygen Supplemental oxygen Suction Suction Chin lift/jaw thrust Chin lift/jaw thrust Oral/nasal airways Oral/nasal airways Definitive airways Definitive airways – RSI for agitated patients with c-spine RSI for agitated patients with c-spine immobilization immobilization – ETI for comatose patients (GCS<8) ETI for comatose patients (GCS<8)
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- 15. Breathing Breathing What canwe look for clinically to assess a What can we look for clinically to assess a patient’s ‘breathing’ status? patient’s ‘breathing’ status?
- 16. B- Breathing B- Breathing Airway patency alone does not ensure Airway patency alone does not ensure adequate ventilation adequate ventilation Inspect, palpate, and auscultate Inspect, palpate, and auscultate – Deviated trachea, crepitus, flail chest, sucking Deviated trachea, crepitus, flail chest, sucking chest wound, absence of breath sounds chest wound, absence of breath sounds CXR to evaluate lung fields CXR to evaluate lung fields
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- 19. Breathing Interventions Breathing Interventions Ventilate with 100% oxygen Ventilate with 100% oxygen Needle decompression if tension Needle decompression if tension pneumothorax suspected pneumothorax suspected Chest tubes for pneumothorax / hemothorax Chest tubes for pneumothorax / hemothorax Occlusive dressing to sucking chest wound Occlusive dressing to sucking chest wound If intubated, evaluate ETT position If intubated, evaluate ETT position
- 20. Chest Tube forGSW Chest Tube for GSW
- 21. What would wedo for this patient What would we do for this patient who is having difficulty breathing? who is having difficulty breathing?
- 22. C- Circulation C- Circulation Hemorrhagic shock should be assumed in Hemorrhagic shock should be assumed in any hypotensive trauma patient any hypotensive trauma patient Rapid assessment of hemodynamic status Rapid assessment of hemodynamic status – Level of consciousness Level of consciousness – Skin color Skin color – Pulses in four extremities Pulses in four extremities – Blood pressure and pulse pressure Blood pressure and pulse pressure
- 23. Circulation Interventions Circulation Interventions Cardiac monitor Cardiac monitor Apply pressure to sites of external hemorrhage Apply pressure to sites of external hemorrhage Establish IV access Establish IV access – 2 large bore IVs 2 large bore IVs – Central lines if indicated Central lines if indicated Cardiac tamponade decompression if indicated Cardiac tamponade decompression if indicated Volume resuscitation Volume resuscitation – Have blood ready if needed Have blood ready if needed – Level One infusers available Level One infusers available – Foley catheter to monitor resuscitation Foley catheter to monitor resuscitation
- 24. D- Disability D- Disability Abbreviated neurological exam Abbreviated neurological exam – Level of consciousness Level of consciousness – Pupil size and reactivity Pupil size and reactivity – Motor function Motor function – GCS GCS » Utilized to determine severity of injury Utilized to determine severity of injury » Guide for urgency of head CT and ICP monitoring Guide for urgency of head CT and ICP monitoring
- 25. GCS GCS EYE EYE VERBAL VERBAL MOTOR MOTOR Spontaneous4 Spontaneous 4 Oriented 5 Oriented 5 Obeys 6 Obeys 6 Verbal 3 Verbal 3 Confused 4 Confused 4 Localizes 5 Localizes 5 Pain 2 Pain 2 Words 3 Words 3 Flexion 4 Flexion 4 None 1 None 1 Sounds 2 Sounds 2 Decorticate 3 Decorticate 3 None 1 None 1 Decerebrate 2 Decerebrate 2 None 1 None 1
- 26. Disability Interventions Disability Interventions Spinal cord injury Spinal cord injury – High dose steroids if within 8 hours High dose steroids if within 8 hours ICP monitor- Neurosurgical consultation ICP monitor- Neurosurgical consultation Elevated ICP Elevated ICP – Head of bed elevated Head of bed elevated – Mannitol Mannitol – Hyperventilation Hyperventilation – Emergent decompression Emergent decompression
- 27. E- Exposure E- Exposure Complete disrobing of patient Complete disrobing of patient Logroll to inspect back Logroll to inspect back Rectal temperature Rectal temperature Warm blankets/external warming device to Warm blankets/external warming device to prevent hypothermia prevent hypothermia
- 28. Always Inspect theBack Always Inspect the Back
- 29. Lets do aCase! Lets do a Case! Stabilize this patient Stabilize this patient
- 30. Case Case 28 yoM involved in a high speed motorcycle accident. He was not 28 yo M involved in a high speed motorcycle accident. He was not wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”. wearing a helmet. He is groaning and utters, “my belly”, “uggghhh”. HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask HR 134 BP 87/42 RR 32 SaO2 89% on 100% facemask Brief initial exam: pt is drowsy but arousable to voice, has large Brief initial exam: pt is drowsy but arousable to voice, has large hematoma over L parietal scalp, airway is patent, decreased breath hematoma over L parietal scalp, airway is patent, decreased breath sounds over R chest, diffuse abdominal tenderness, obvious deformity sounds over R chest, diffuse abdominal tenderness, obvious deformity to L ankle to L ankle
- 31. ABCDE ABCDE What arethe management priorities at this What are the management priorities at this time? time? What are this patient’s possible injuries? What are this patient’s possible injuries? What are the interventions that need to What are the interventions that need to happen now? happen now?
- 32. Secondary Survey Secondary Survey AMPLE history AMPLE history – Allergies, medications, PMH, last meal, events Allergies, medications, PMH, last meal, events Physical exam from head to toe, including Physical exam from head to toe, including rectal exam rectal exam Frequent reassessment of vitals Frequent reassessment of vitals Diagnostic studies at this time simultaneously Diagnostic studies at this time simultaneously – X-rays, lab work, CT orders if indicated X-rays, lab work, CT orders if indicated – FAST exam FAST exam
- 33. HEENT HEENT What are thenames of these signs? Battle ear Raccoon’s eye
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- 35. Diagnostic Aids Diagnostic Aids Standard trauma labs Standard trauma labs – CBC, K, Cr, PTT, Utox, EtOH, ABG CBC, K, Cr, PTT, Utox, EtOH, ABG Standard trauma radiographs Standard trauma radiographs – CXR, pelvis, lateral C-spine (traditionally) CXR, pelvis, lateral C-spine (traditionally) CT/FAST scans CT/FAST scans Pt must be monitored in radiology Pt must be monitored in radiology Pt should only go to radiology if stable Pt should only go to radiology if stable
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- 37. Tension Pneumothorax Tension Pneumothorax Howdo you treat this? How do you treat this?
- 38. Hemothorax Hemothorax Is this patientlying or upright? Is this patient lying or upright?
- 39. Widened Mediastinum Widened Mediastinum Whatdisease process does this indicate? What disease process does this indicate?
- 40. Bilateral Pubic RamusFractures and Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption Sacroiliac Joint Disruption What should this injury make you worry about? What should this injury make you worry about?
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- 42. Subdural Hematoma withSAH Subdural Hematoma with SAH
- 43. Abdominal Trauma Abdominal Trauma Common source of traumatic injury Common source of traumatic injury Mechanism is important Mechanism is important – Bike accident over the handlebars Bike accident over the handlebars – MVC with steering wheel trauma MVC with steering wheel trauma High suspicion with tachycardia, High suspicion with tachycardia, hypotension, and abdominal tenderness hypotension, and abdominal tenderness Can be asymptomatic early on Can be asymptomatic early on FAST exam can be early screening tool FAST exam can be early screening tool
- 44. Abdominal Trauma Abdominal Trauma Look for distension, tenderness, seatbelt Look for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal marks, penetrating trauma, retroperitoneal ecchymosis ecchymosis Be suspicious of free fluid without evidence of Be suspicious of free fluid without evidence of solid organ injury solid organ injury
- 45. Splenic Injury Splenic Injury Most commonly injured organ in blunt trauma Most commonly injured organ in blunt trauma Often associated with other injuries Often associated with other injuries Left lower rib pain may be indicative Left lower rib pain may be indicative Often can be managed non-operatively Often can be managed non-operatively Spleen with surrounding blood Blood from spleen Tracking around liver
- 46. Liver injury Liver injury Second most common solid organ injury Second most common solid organ injury Can be difficult to manage surgically Can be difficult to manage surgically Often associated with other abdominal injuries Often associated with other abdominal injuries Liver contusions
- 47. What’s wrong withthis picture? What’s wrong with this picture? May only see the nasogastric tube appear to be coiled May only see the nasogastric tube appear to be coiled in the lung. in the lung. Left > right due to liver protection of the diaphragm. Left > right due to liver protection of the diaphragm. Trace the Diaphragm Outline. Where is the Diaphragm on the left? Abdominal contents Up in the chest on the left
- 48. Hollow Viscous Injury HollowViscous Injury Injury can involve stomach, bowel, or mesentery Injury can involve stomach, bowel, or mesentery Symptoms are a result from a combination of blood loss and Symptoms are a result from a combination of blood loss and peritoneal contamination peritoneal contamination Small bowel and colon injuries result most often from Small bowel and colon injuries result most often from penetrating trauma penetrating trauma Deceleration injuries can result in bucket-handle tears of Deceleration injuries can result in bucket-handle tears of mesentery mesentery Free fluid without solid organ injury is a hollow viscus injury Free fluid without solid organ injury is a hollow viscus injury until proven otherwise until proven otherwise
- 49. Mesenteric and bowelinjury from blunt abdominal trauma. Notice the bowel and mesenteric disruption. bowel mesentery
- 50. CT Scan inTrauma CT Scan in Trauma Abdominal CT scan visualizes solid organs Abdominal CT scan visualizes solid organs and vessels well and vessels well CT does NOT see hollow viscus, CT does NOT see hollow viscus, duodenum, diaphram, or omentum well duodenum, diaphram, or omentum well Some recent surgery literature advocates Some recent surgery literature advocates whole body scans on all trauma whole body scans on all trauma – Keep in mind that there is an increase in Keep in mind that there is an increase in mortality related to cancer from CT scans mortality related to cancer from CT scans
- 51. FAST Exam FAST Exam Focused Abdominal Scanning in Trauma Focused Abdominal Scanning in Trauma 4 views: Cardiac, RUQ, LUQ, suprapubic 4 views: Cardiac, RUQ, LUQ, suprapubic Goal: evaluate for free fluid Goal: evaluate for free fluid See normal Liver and kidney Free fluid in Morrison's Pouch between liver and kidney
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- 53. Non-accidental Trauma Non-accidental Trauma Key is SUSPICION!!! Key is SUSPICION!!! Incongruent stories of mechanism Incongruent stories of mechanism Delay in seeking treatment Delay in seeking treatment Multiple stages of injuries Multiple stages of injuries Pattern Injuries Pattern Injuries Multiple hospital visits Multiple hospital visits Injury mechanism beyond the scope of the age of Injury mechanism beyond the scope of the age of child (6week old rolled over off the bed) child (6week old rolled over off the bed) Bite marks, submersion injury, cigarette burns Bite marks, submersion injury, cigarette burns
- 54. Disposition of TraumaPatients Disposition of Trauma Patients Dictated by the patient’s condition and available Dictated by the patient’s condition and available resources i.e. trauma team available resources i.e. trauma team available – OR, admit, or transfer OR, admit, or transfer Transfers should be coordinated efforts Transfers should be coordinated efforts – Stabilization begun prior to transfer Stabilization begun prior to transfer – Decompensation should be anticipated Decompensation should be anticipated Serial examinations Serial examinations – CHI with regain of consciousness CHI with regain of consciousness – Abdominal exams for documented blunt trauma Abdominal exams for documented blunt trauma – Pulmonary contusions with blunt chest trauma Pulmonary contusions with blunt chest trauma
- 55. Summary Summary Trauma isbest managed by a team Trauma is best managed by a team approach (there’s no “I” in trauma) approach (there’s no “I” in trauma) A thorough primary and secondary survey A thorough primary and secondary survey is key to identify life threatening injuries is key to identify life threatening injuries Once a life threatening injury is discovered, Once a life threatening injury is discovered, intervention should not be delayed intervention should not be delayed Disposition is determined by the patient’s Disposition is determined by the patient’s condition as well as available resources. condition as well as available resources.
- 56. Sources Sources ATLS StudentCourse Manuel, 6 ATLS Student Course Manuel, 6th th edition. edition. Rosen’s Emergency Medicine Concepts and Rosen’s Emergency Medicine Concepts and Clinical Practice, 5 Clinical Practice, 5th th edition. edition. Emergency Medicine A Comprehensive Emergency Medicine A Comprehensive Study Guide, 5 Study Guide, 5th th edition. edition.
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Editor's Notes
- #23 Contraindications of foley catheter (signs of possible urethral injury): 1. Blood at urethral meatus 2. Perineal eccymosis 3. Blood in the scrotum 4. High riding prostate 5. Pelvic Fractures If suspicious of urethral injury---retrograde urethrogram prior to insertion
- #31 . Always ABCDE first! A – airway patent; go to NRB mask, frequent reassessment, don’t forget proper C-spine immobilization B – tachypnea, decr. BS, hypoxia (? PTX, hemothorax); consider needle decompression , CXR, then chest tube C- hypotensive, tachycardic (? Tension PTX v. massive hemothorax v. intraabdominal hemorrhage, ? Pelvic fractures); needs large bore IV v. CVL, IVF, blood available D – do quick GCS, pupils, motor assessment E – exposure, blankets