Issues in Trauma Lynne Fulton May 27, 2009

Intro No basics My backround “Demanded efficient and thoughful care by other team members” Observing a patient is often more valuable than DOING SOMETHING

OBJECTIVES DISCUSS: CONTROVERSIES IN TRAUMA MANAGEMENT PENETRATING NECK TRAUMA UNUSUAL PROBLEMS GERIATRIC ISSUES QUESTIONS - for which I will not have answers!

Controversies Fluid resuscitation and intubation in trauma patients Trauma = 2nd most important condition for children and 4th most important for adults in pre-hospital care

OPALS Major Trauma Study 2008, CMAJ Major trauma (ISS>12) Adults (>16 years) 17 urban centres Pre and post Advanced Life Support being introduced

2867 patients Stats re age, sex, mechanism, injury severity matched Excluded: Toronto and Hamilton, dead at scene, injuries 8 hours prior to EMS being called All treated at lead trauma hospitals

Previous study showed no impact on outcomes for patients with cardiac arrests Previous study showed improved outcome in patients with respiratory distress

Primary interventions were intravenous fluids and endotracheal intubation

No substantial difference in survival to discharge (81.8% for basic life support, and 81.1% for advanced life support) No difference in early deaths (<24 hrs) No difference in morbidity based on GCS and functional independence at discharge and 6 months

If GCS less than 9, survival was lower with advanced life support ALS associated with increased mortality, intubation associated with increased mortality, IV therapy associated with no change in mortality

Other studies have come to similar conclusions Penetrating torso injuries have increased survival, earlier discharge, and fewer complications with delayed fluid administration Increased compartment syndromes with aggressive fluid administration early in limb trauma

? Rural versus urban situations Why -increased scene time -increased bleeding due to increased BP - hyperventilaton

Scoop and run seems more effective in urban settings

Penetrating Neck Injuries 5-10% of traumatic injuries in US Increased incidence in Canada Mass casualty situations

Zones Zone 1 = clavicle to cricoid cartilage Zone 2 = cricoid cartilage to angle of the mandible Zone 3 = angle of the mandible to base of the skull

Incidence by Zone Zone 2 most common Zone 1 second Zone 3 least

Associated Injuries Aerodigestive tract -10% laryngeal or tracheal injuries -9.6% esophageal injuries -Vascular - venous 9% - Arterial 6.7%

Zones can be transgressed

Principles Immediate transfer to nearest trauma centre Do not remove projectile if present Do not explore the wound

Airway Oral intubation preferred If airway injury is present (sucking wound or subcu emphysema or bubbling wound) bag valve mask can lead to problems

Consider chest injuries

Control bleeding with direct pressure Transport in position to allow adequate respirations A neuro deficit may be due to a vascular injury, and intact pulses do not rule out vascular injury

Cases A 25 year old woman is struck by a car while standing at a bus stop, and thrown 20 feet. She is VSA. She is intubated and given epi (1 dose) and regains a pulse and blood pressure. What is her primary injury?

Cases A young woman is a belted driver in a car involved in a minor motor vehicle accident on Bayview Avenue and her airbag deployed. She was DOA on arrival at the hospital. What happened?

Cases A young man presented from a motor vehicle accident with a decreased level of consciousness and a laceration of his cheek. Ventilation was attempted with a bag valve mask, and was not successful. Why?

Cases A head injured patient, who was hyperventilating, was nasally intubated, and aspirated the tube. What happened?

Geriatric Issues Under-triage is the norm Outcomes are poorer Reflexes are slower Meds are more common