Download - Primary Trauma Care
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PTCPTC
Primary TraumaPrimary TraumaCareCare
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PTCPTC
objectivs :objectivs :
1- Early diagnosis & management of traumatic brain injury
• 2- prevent causes of secondary brain injury during resuscitation ( hypoxia, hypovolemia, hypocarbia , anemia , hypo/hyperglycemia)
• 3- To rapidly identify & treat mass lesions
• 4- indications for ICP/CPP monitoring & management of intracranial hypertension
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PTCPTC
Head TraumaHead Trauma
• 1/3-1/2 of trauma deaths• Good outcomes possible without
CT scans and neurosurgeons• Aim to avoid secondary brain injury• Hypoxia and hypotension double
mortality
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PTCPTC
Head TraumaHead TraumaApproachApproach
Airway
Breathing
Circulation
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PTCPTC
Airway :Airway :
• 1-intubate all unconscious patient (GCS <9 ) to secure airway
• 2- Maintain cervical spine immobilization in all unconscious or symptomatic (neck pain or tenderness ) patients
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PTCPTC
BreathingBreathing
• 1- administer high flow oxygen to all patient with suspected head injury
• 2- monitor oxygen saturation• Avoid hypoxia (SaO2<90% or PaO2 <60 mmhg
• 3- ventilation• Avoid hyperventilation , unless sign of herniation are present• Maintain PaCO2 35-40 mmhg
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PTCPTC
CirculationCirculation
• 1- prehospital : avoid SBP < 90 mmHg
• 2- maintain MAP > 90 mmHg to maintain CPP >60 mmHg
• 3- Fluid : infuse 0.9 NaCl & or blood
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PTCPTC
Head TraumaHead TraumaPhysiologyPhysiology
CPP = MAP - ICP
CPP = cerebral perfusion pressureMAP = mean arterial pressure
ICP = intracranial pressure
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PTCPTC
Cerebral Blood FlowCerebral Blood FlowDepends on:Depends on:
• CPP (MAP-ICP)
• PaCO2
• PaO2
• Local metabolites
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PTCPTC
Intracranial Pressure (ICP) Intracranial Pressure (ICP)
• 10 mm Hg = Normal
• > 20 mm Hg = Abnormal
• > 40 mm Hg = Severe
• Sustained ICP leads to brain
function and outcome
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PTCPTC
cerebral Perfusion Pressurecerebral Perfusion Pressure
MBP - ICP = CPP
• Normal 90 - 10 = 80
• Cushing’s 100 - 20 = 80
Response
• Hypotension 50 - 20 = 30
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PTCPTC
TreatmentTreatment
• Minimize secondary brain injury• - ABCDE• - Maintain CPP• - Maintain blood pressure (systolic > 90 mm
Hg)• - Reduce ICP
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PTCPTC
TreatmentTreatment
• Maintain MAP• – Euvolaemic fluid resuscitation• – Isotonic fluids• – Inotropes
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PTCPTC
TreatmentTreatment
• Reduce ICP• – Controlled ventilation• Goal: PaCO2 at 35 mm Hg• – Head up tilt• – Paralysis• – Mannitol• – Surgery
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PTCPTC
TreatmentTreatment
• Mannitol• Use with signs of tentorial
herniation• Dose: 1.0 g / kg IV bolus
Consult with neurosurgeon first
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PTCPTC
Head TraumaPathophysiology
• Primary Injury
occurs at time of injury
• Secondary Injury
occurs after injury
may be preventable
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PTCPTC
Head TraumaPrimary injury
Diffuse axonal injury - Acceleration
- deceleration Cerebral contusion Penetrating injury
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PTCPTC
Head Trauma Secondary injury
Hypoxia Hypoperfusion (↑ ICP, ↓ MAP) Hypoglycaemia Hyperthermia (fever) Seizures
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PTCPTC
Head TraumaHead TraumaInitial assessmentInitial assessment
Airway (+ C-spine)
Breathing
Circulation
Disability (AVPU, pupils)
Exposure
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PTCPTC
Head TraumaHead TraumaExaminationExamination
• Glasgow Coma Score• Pupils• Corneal reflex• Eye position • Fundi
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PTCPTC
Head TraumaHead TraumaExaminationExamination
• Tympanic membrane• Scalp and skull• Respiratory Pattern• Muscle tone• Posture• Tendon reflexes
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PTCPTC
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PTCPTC
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PTCPTC
Head Trauma Head Trauma Glasgow Coma Score (GCS)Glasgow Coma Score (GCS)
• Grades severity of head injury• Score out of 15• Subject to inter-observer variation• Trend of GCS over time very useful• Also important to describe responses
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PTCPTC
Head Trauma Head Trauma GCS Eye openingGCS Eye opening
Open spontaneously 4
Open to command 3
Open to pain 2
None 1
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PTCPTC
Head Trauma Head Trauma GCS Best Verbal Response GCS Best Verbal Response
Oriented 5
Confused 4
Inappropriate words 3
Inappropriate sounds 2
None 1
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PTCPTC
Head TraumaHead TraumaGCS Best Motor ResponseGCS Best Motor Response
Obeys command 6Localises to pain 5Withdraws to pain 4Abnormal flexion 3Extensor response 2None 1
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PTCPTC
Head Trauma Head Trauma Severity of Head InjurySeverity of Head Injury
Severe GCS <8
Moderate GCS 9-12
Minor GCS 13-15
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PTCPTC
Head Trauma Head Trauma Pupillary signsPupillary signs
• Size• Reactivity• Equality
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PTCPTC
Head Trauma Head Trauma Pupillary responsesPupillary responses
Fixed, dilated,
unresponsive
• Severe hypoxia• Hypothermia• Seizures
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PTCPTC
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PTCPTC
Head Trauma Head Trauma Pupillary responsesPupillary responses
Unilateral, dilated,
unresponsive
• Expanding lesion on same side
• Tentorial herniation
• Seizures
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PTCPTC
Head TraumaHead TraumaAcute extradural or subduralAcute extradural or subdural
• Potentially life-threatening• Immediate recognition essential• Require burr-hole decompression
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PTCPTC
Head TraumaHead TraumaAcute extraduralAcute extradural
• LOC → lucid interval → deterioration• Middle meningeal artery bleed• Overlying skull fracture• Contralateral hemiparesis• Fixed pupil on side of injury
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PTCPTC
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PTCPTC
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PTCPTC
Head TraumaHead TraumaAcute subduralAcute subdural
• Tearing of bridging vein between cortex and dura
• Underlying brain injury• Usually no lucid interval• Worse prognosis than extradural
haematoma
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PTCPTC
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PTCPTC
Head TraumaHead TraumaOther injuriesOther injuries
• Base-of-skull fractures• Cerebral concussion• Depressed skull fracture• Intracerebral haematoma
Usually do not require neurosurgery
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PTCPTC
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PTCPTC
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PTCPTC
AirwayBreathing (ventilation)Circulation + Avoid ↑ ICP
Aim to prevent secondary injury
Head TraumaHead TraumaManagementManagement
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PTCPTC
Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)
• Intubate• Normal CO2
• Treat hypotension with fluid • Sedation +/- paralysis
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PTCPTC
Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)
• Nurse head up 20o
• Prevent hyperthermia• Complete secondary survey• Reassess frequently
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PTCPTC
Head TraumaHead TraumaBewareBeware
• Deteriorating conscious state• Penetrating injury• Focal neurological signs
- unequal, dilated pupils
- seizures
- posturing
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PTCPTC
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PTCPTC
Head TraumaHead Trauma
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PTCPTC
Head TraumaHead Trauma
Summary• ABCs• Prevent secondary injury• Isolated head trauma doesn’t cause
hypotension • Look for other injuries• Deterioration → reassess
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PTCPTC
Spinal TraumaSpinal Trauma
Objectives• To understand the structured
approach to the patient with spinal trauma
• To learn how to identify serious and life-threatening spinal injuries
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PTCPTC
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PTCPTC
Spinal TraumaSpinal TraumaPrimary surveyPrimary survey
Airway + Cervical spine
Breathing
Circulation
Disability
Exposure
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PTCPTC
Spinal TraumaSpinal TraumaSecondary surveySecondary survey
• Examine in neutral position• Log-roll to examine back• Immobilise
- stiff neck collar
- sandbags + tapes
- in-line immobilisation
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PTCPTC
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PTCPTC
Spinal TraumaSpinal TraumaSecondary surveySecondary survey
• Local tenderness• Swelling• Deformity and stepping
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PTCPTC
Spinal Trauma Spinal Trauma Assessment of levelAssessment of level
• Motor response• Sensory response
• Especially sacral sparing
• Reflexes• Autonomic function
• Bowel control• Bladder control
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PTCPTC
Spinal Trauma Spinal Trauma High risk for C-spineHigh risk for C-spine
• Head injury• Paradoxical (diaphragmatic)
breathing• Flaccid limbs• No reflexes (check rectal sphincter)• Hypotension (+bradycardia)
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PTCPTC
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PTCPTC
normals
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PTCPTC
Dens #
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PTCPTC
Unifacet dilocation
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PTCPTC
Spinal TraumaSpinal TraumaTransportTransport
• Never transport in sitting or prone position
• Stabilise spine prior to movement• Log roll for transfer
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PTCPTC
Spinal TraumaSpinal Trauma
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PTCPTC
Spinal TraumaSpinal Trauma
Summary• Immobilise until injury is excluded• Initial management is ABC• Thorough neurological examination
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