Primary survey and Resuscitation of trauma patient

Shivani gabaJR-III ,OMFS

TRAUMA-FACTS Trauma is the leading cause of death from birth to age 44 years.

It is third only to cancer and atherosclerosis in all age groups.

Worldwide ,approx. 50 million people are severely or moderately disabled as a result of trauma and more than 180 million disability adjusted life years are lost each year.

The burden of trauma constitutes 12% of world’s total disease load. It is estimated that global financial cost of trauma exceeds U.S. $500 billion annually.

Trauma is one of the few disease categories in which mortality is increasing.

More than 20 % of trauma patients come from RTAs. Others from sports related injuries, interpersonal violence , occupational injuries, and falls.

The ideal hospital is level –I trauma centre where all medical specialties ,with full back up infrastructure ,are on site 24 hours a day.

TRAUMA CARE CONTINUUMTrauma

Arrival of emergency services

Resuscitation room management

Transfer to hospital

Definitive care

Discharge from hospital

Long-term support services

Objectives

AIMS OF TRAUMA CARE

PREHOSPITAL CARE

INITIAL ASSESSMENT OF PATIENT

PRIMARY SURVERY AND RESUSCITATION A B C D E F

AIMS OF TRAUMA CARE

•Identification of major trauma patient at scene of incident

•Immediate intervention to allow safe transport

•Rapid transfer to appropriate trauma centre for surgical management and critical care

•Coordinated specialist recontruction

•Targeted comprehensive rehabilitation

Prehospital care

•Need to identify and deliver to a place of definitive care safely and quickly

•Ambulance services vehicles are outfitted with essential equipments necessary to provide immediate resuscitation

•Ambulance control room-102•Emergency & management disaster services-108•Road accident emergency services on national highway-1073•Railway accident emergency sevices-1072

Trained paramedics – Assess the victims - Providing basic life support - Communicate with planned receiving hospital regarding no.of patients and time of arrival

TRIAGE

Triage is sorting of patients based on their need for treatment and the available resources to provide the treatment . It can be field triage, done by paramedics at the accident scene, who decide what level of care is required and therefore to which hospital the patient needs to be transferred. It may also be done at receiving hospital –which patients need immediate ,life saving intervention, which can wait, and which are ,in fact, beyond saving.

Multiple casualtiesTerm used when the number of patients and severity of their injuries do not exceed the ability of the facility to provide care . Patients with life threatening problems and those who have sustained multiple system injuries are treated first.

Mass casualtiesTerm used to describe the situation in which no. of patients and the severity of injuries exceed the capability of the facility and staff. Those who have greatest chances of survival with the least expenditure of time, supplies , equipments, and personnel are managed first.

Best environment for resuscitation is a safe ,warm ,dry, well lit,fully staffed and eqipped area with complete backup resourses.

Role of Maxillofacial surgeonThe involvement of maxillofacial surgeon in trauma teams has significant benefits in terms of training and in the early identification and optimal management of craniofacial trauma. As a member of trauma team he/she must be skilled in TLST and capable of dealing with both specialty specific problems and other life threatening cond.Expertise concerning midface injuries and any potential threat to eyesight from trauma and heamorrhage is invaluable.

A formally constituted trauma team ,ideally comprising specialist anesthetic, surgical, and orthopedic component in addition to emergency Deptt. Staff.All members should have appropriate training ,such as the ALTS course, which has become the gold standard and common language of trauma management.

Protective clothing

•Immunization against tetanus , hep b•Start the clock•Transferring patient from strecter to trolly

Preparation at receiving hospital

Always speak to the pre-hospital team

Initial assessment of patient

Deaths from trauma follow a trimodel distribution.The first peak,contituting 40-50% of trauma deaths,occur immediately or within minutes of accident at the scene.cause-laceration of brain,brainstem,high spinal cord,heart,aorta,or other large vessels.due to severity of injuries very few of these patient survive. cannot be saved no matter what intervention or skill level is available immediately around themTo prevent:safer roads,speed restriction,air bags, and speedy arrival of paramedics..Second peak:-30% of trauma deaths.who arrive alive to hospital but succumb to injuries over next minutes or hours is period referred to as golden hour..die largely from hypoxia and hypovolemic shock as a chest injuries,abdominal trauma,orthopedic ,intracranial heamatomas.Third peak:who succumb days or even weeks after traumatic incident because of MOF,sepsis.RD.

The immediate assessment and early management of trauma patent is comprehensively covered by ATLS course . ATLS focuses on the second peak, because apprehensive and timely intervention in the resuscitation room will both save lives and minimize morbidity, thereby also reducing the third peak in the subsequent definitive care period lasting days or weeks.

Primary survey and resuscitationIn the resuscitation room a rapid primary survey is carried out. care must follow the safest pathway, diagnosing and simultaneously treating life threatening injuries in the order in which they would otherwise kill the patient.

As each most pressing killer injury is treated, more resuscitation time is created to deal with the next most pressing problem.

Each patient should be assessed in the same way and appropriate tasks should be performed automatically and simultaneously by the team..To facilitate this ,the primary survey of patient follow a strict sequential “ABCDE” protocol

•Airway with cervical Spine Control

•Breathing and Ventilation

•Circulation and Hemorrhage Control

•Disability- (Neurological status )

•Exposure + environment — completely undress the patient, but prevent hypothermia

To these, another point may be added:

•Frequent Reassessment must be made

It is essential to ensure that prehospital personnel provide a comprehensive account of the accident scene.• patient details• important information such as the time of the accident, other factors such as fires, explosions, hazardous chemicals, and injuries sustained by other victims. •Photographs taken at the scene also provide vital informa tion* what injuries might be anticipated (index of suspicion).13

Maxillofacial injuries are addressed at this stage only if they have an impact on the airway, breathing, or circulation. Comprehensive assessment and definitive management of maxillofacial injuries occur later, away from the resuscitation room setting.

•Priorities for care of the pediatric patient are the same as for adults,

• Priorities for care of the pregnant woman are similar to those for nonpregnant patients. Pregnancy should be identified early by palpation of the abdomen for a gravid uterus and by laboratory testing for human chorionic gonadotropin (HCG). Early fetal assessment is important for maternal and fetal survival.

In the elderly, comorbidities* are more common, and, together with the aging process, they reduce the patient's functional reserve and ability to respond to injury. The chronic use of medications The narrow therapeutic window frequently leads to overresuscitation or underresuscitation in the elderly, and early invasive monitoring is valuable.

Do no further harm

High index of suspicion for cervical spine injury :•if the patient has maxillofacial injuries or multisystem trauma,•if the level of consciousness is altered,• if there is a history of a high-speed impact.

Approximately 15% of patients with supraclavicular injuries also and 5% of head-injured patients have some form of associated spinal injury.

Therefore, great care should be taken to prevent exces sive movement of the cervical spine during assessment and management of a patient's airway.

A: AIRWAY AND CERVICAL SPINE CONTROL

Traumatic atlantoaxial subluxation /dislocation (Atlantoaxial instability is defined by an increase in the predentate space of greater then 3 mm in adults and 5 mm in children) usually results from a motor vehicle collision in which an unrestrained occupant’s head strikes the windshield or dashboard .

Predictable Patterns of Intracranial and Cervical Spine Injury in Craniomaxillofacial Trauma: Analysis of 4,786 Patients. 2008 .AAPS.Annual Meeting Abstracts

Assume cervical spine injury and maintain the spine in neutral (by using backboards, bindings,and purpose build head immobolizers) until proven otherwise clinically and radiographically.Use of soft semirigid collars –discourage!

During intubation it is acceptable to remove the hard collar to aid jaw movement so long as someone performs ‘manual in line immobilisation’ of the head and neck ,achieved simply and quickly by placing one hand on either side of the patient's head and holding the head in a neutral position, taking care not to cover the ears.

Assurance of an airway is the first step in all emergency medicine protocols

The First Step

•Oxygen is essential to life!

Physically disrupted airway is obviously a major challenge

An assessment must immediately be made as to whether the patient can maintain and protect his or her own airway. The most sophisticated of tecniques in treating facial trauma can be meaningless if attention is not first directed to airway.

Much information can be gained very quickly by asking the patient a simple question such as "How are you?" or "What happened?“

If the patient gives an appropriate and. coherent response, it suggests that the airway (A) is clear, that-breathing and ventilation (B) are sufficiently effective to deliver enough oxygen into the circulation (C), which is functional sufficiently to transport the oxygen to the brain (D) which in turn is functioning sufficiently to allow the patient to comprehend and respond. However, there is a significant caveat: Although the patient's ABCD factors may be functioning sat isfactorily at the time of questioning, they

may not be shortly, so that frequent re-examination is essential.

Airway management options include:

O2 administration

·Basic airway manouvers: chin lift+ jaw thrust·Oropharyngeal or nasopharyngeal airway- but caution with bleeding·Endotracheal intubation·Surgical airway ie Cricothyroid/Tracheostomy

Basic Airway ManeuversSupplemental oxygen delivered through a well-fittpH rpgpr-voir (rebreathing) mask, at a rate ot 15 L/min to achieve maximum oxygenation of the tissues, should be given to every trauma patient.

If the patient fails to respond to questioning, formal airway assessment must be immediately instigated. As always, clini cal assessment should follow the protocol, "Look, Listen, and Feel.“

Look to see if the patient is agitated or obtunded. Agitation suggests hypoxia, and obtundation suggests hypercarbia. Cyanosis indicates hypoxemia and can be seen in the lips arid nailbeds. Look for the pattern of breathing and use of accessory muscles of ventilation. Look for facial burns; singed eyebrows, facial hair, or nasal "vibrissae; and soot around the lips, in the mouth, or in the sputum (indicating burn injury, inhalational burns, and possibly impending airway obstruction).Listen for abnormal sounds. Noisy breathing is obstructed breathing. Snoring, gurgling, and crowing noises (stridor) may be associated with partial obstruction of the pharynx or larynx. Hoarseness implies functional laryngeal obstruction. The abusive or belligerent patient may hypoxic and should not be presumed to be intoxicated.

Feel: for the location of the trachea and determine whether it is in the midline. The mouth should be opened and any foreign objects (e.g., fractured teeth, fillings, dentures) should be removed. The mouth is examined, and any fluid is sucked out. The nature and volume of the fluid (secretions, blood) and evidence of pooling in the oropharynx indicate loss of airway control by the patient.

In an unconscious patient who is lying supine the tongue may fall back and obstruct the airway; a simple chin lift or jaw thrust maneuver can be used to correct the-tongue position and open the airway. A jaw thrust is performed by grasping the angles of the mandible with one hand on each side and displacing the mandible forward. If the patient is breathing spontaneously, high-flow oxygen via the facemask and resevoir bag will provide good oxygenation and ventilation. If the patient is not breathing, a facemask with a bag-valve device (Ambubag) connected to the oxygen supply and compressed by an assistant will work until formal management of the airway is achieved.

A chin lift should be performed without hyper extending the patient's neck. The mandible is gently lifted upward using the fingers of one hand placed under the chin. The thumb of the same hand lightly depresses the lower lip to open the mouth

The oropharyngeal airway must not he used in a conscions patient, became it may induce coughing. gagging vomiting, and aspiration. During its insertion, care must be taken not to push the tongue backward and thereby block rather than clear the airway. Those patients with a gag reflex can maintain their own airway. The use of oropharyngeal (Guedel) airways in these patients can precipitate vomiting, neck movement, and a rise in intracranial pressure; therefore, a nasopharyngeal airway is preferred, provided there is no evidence to suggest a fracture of the base of the skull.

If the patient vomits, the patient’s head should not be moved to one side unless cervical spine injury has been excluded If the patient is secured on a spinal board, the whole board can be turned. In the absence of a spinal board, the whole gurney should be tipped so that the head is down and the vomit sucked away with a rigid sucking device.

In a conscious patient, a well-lubricated nasopharyngeal airway is inserted in the nostril that appears to be unobstructed and passed gently into the posterior oropharynx. If obstruction is encountered during introduction of the airway, the procedure is stopped and then retried on the other side.

The laryngeal mask airway (LMA) has an established role in routine surgery to provide a protected airway and also in patients with difficult airways, particularly if orotracheal intubation has failed or bag-mask ventilation is not maintain ing sufficient oxygenation. However, it is not a definitive airway because there is no cuffed tube in the trachea. Also, some training is required to use it, and it can be displaced relatively easily. If a patient presents with an LMA already in place, conversion to a definitive airway must be planned.

A multilumen esophageal airway is a form of LMA that has two tubes, enabling occlusion of the esophagus to reduce the risk of aspiration. However, it does not have a cuffed tube in the trachea and therefore does not constitute a definitive airway.

Advanced Airway Maneuvers: Definitive AirwayA definitive airway is defined as an inflated cuffed tube in the Trachea.types: the orotracheal tube, the nasotracheal tube, and the surgical airway (crico-thyroidotomy or tracheostomy).

A definitive airway should be considered if any of the following is present:•Apnea•Inability to maintain a patent airway by other means•The need to protect the lower airway from blood or vomit•Potential compromise of the airway (e.g., after burn injury, other inhalational injury, facial fractures, retropharyngeal hematoma, or sustained seizure activity)•A closed-head injury requiring assisted ventilation (Glasgow Coma Scale [GCS] score of 8 or less).•Inability to maintain adequate oxygenation by facemask oxygen supplementation

Orotracheal intubation with cervical in-line immo bilization is recommended, rather than blind nasotracheal intubation, especially if a base-of-skull fracture is suspected. If this proves to be difficult, a surgical airway is then considered.

The most important determinant of whether to proceed with orotracheal or nasotracheal intubation is the experience of the doctor. Nasotracheal intubation should not be attempted in an apneic patient nor undertaken if a fracture of the base of the skull is suspected.

The route of choice for securing the airway depends on several factors(cervical injury)Laryngoscope and orotracheal intubation are generally considered to be safe procedures and can be accomplished with minimal changes in the position of the neck when performed by a competent operator with ILI.

This should all take less than 1 minute