1. Severe trauma Lecture overview
The lecture is based around a fictional case with teaching points illustrated as they arrive. One of the major teaching points is that injuries need to be dealt with in order of their potential risk to life. Although trauma management is presented as an orderly progression through primary and secondary survey and then treatment, this is not how severe trauma is, or should be, managed..

2. Trauma management Primary survey Primary survey Secondary survey
Investigations
Investigations
The basis of trauma management is to identify and treat injuries in order of their potential risk to life. As a result management is rarely an orderly progression through primary survey, secondary survey, investigations and treatment. Often secondary survey and investigations may have to be delayed until after problems identified by the primary survey have been dealt with.
Treatment
Treatment

3. Motor vehicle crash 25 year old driver Frontal impact
Impact speed 60 kph
Wearing seat belt
Illustration ©Kathy Mak, 2004

4. Motor vehicle-pedestrian
Mechanism of injury
Related injuries
Frontal impact
Cervical spine fracture, anterior flail chest, myocardial contusion, pneumothorax, transection of aorta, ruptured liver/spleen, fracture/dislocation of hip and/or knee
Side impact
Cervical spine fracture, lateral flail chest, pneumothorax, ruptured spleen/liver (depending on side of impact), fracture of pelvis/acetabulum
Rear impact
Cervical spine injury
Motor vehicle-pedestrian
Head injury, thoracic and abdominal injuries, fracture of lower extremities
The likely injuries can to some extent be predicted from the mechanism of injury. Patients involved in frontal impact vehicle injuries are more likely to suffer cervical spine fractures, anterior flail chest, myocardial contusion, pneumothorax, aortic tear, ruptured liver or spleen and fracture/dislocation of hip/knee

5. Airway “Mist” Bag inflating/deflating
Priority is primary survey and immediate resuscitation
Illustration ©Kathy Mak, 2004

6. Airway No stridor Palpable gas movement “Mist”
Illustration ©Kathy Mak, 2004

7. Breathing Using accessory muscles  Chest movement
Illustration ©Kathy Mak, 2004

8. Breathing Respiratory rate 35/min Unrecordable SpO2
Decreased breath sounds on left
? Hyper-resonance on left
Tracheal deviation to right
Illustration ©Kathy Mak, 2004

9. Circulation BP 80/50, HR 120/min Neck veins distended Cold peripheries
Slow capillary refill
Illustration ©Kathy Mak, 2004

10. Shock Usually due to hypovolaemia Consider Tension pneumothorax
Cardiac tamponade
Myocardial contusion
Myocardial infarction

11. Tension pneumothorax Clinical features Respiratory distress HR, shock
Tracheal deviation (late sign)
Unilateral absence of breath sounds and hyper-resonance (subtle sign)
Distended neck veins
often absent if there is concomitant hypovolaemia
ΔΔ cardiac tamponade

12. Needle thoracostomy 2nd ICS, MCL Gush of air confirms diagnosis
Illustration ©Kathy Mak, 2004

13. Next stage… Intravenous access Chest drain 14G-16G x 2 at least
28F-36F
5th Intercostal space
Just anterior to MAL
Chest drain should always be inserted following needle thoracostomy
Illustration ©Kathy Mak, 2004

14. Chest movement symmetrical
Circulation improves
BP 90/60
Pulse oximeter 95%
Tachypnoeic
Chest movement symmetrical
Illustration ©Kathy Mak, 2004

15. Haemodynamic resuscitation
Aim for systolic BP mmHg in patients who have not suffered head or spinal injuries
Resuscitation to a higher BP may:
Disrupt blood clots
Exacerbate dilutional coagulopathy
Exacerbate hypothermia

16. CXR
Perform early
CXR should be performed early although the exact timing is not important. As the patient has now stabilized this is a good opportunity to take the film. However remember that a CXR is the one X-ray that is justified in an unstable patient. In our patient the CXR shows left sided rib fractures and contusion of the left lung and a chest drain that has been inserted too far

17. Disability Glasgow Coma Score Pupils Decision: E2, V2, M4
3 mm, equal, reactive
Decision:
Intubate & ventilate
for airway protection
Illustration ©Kathy Mak, 2004

18. Cervical spine injury
Cannot be excluded on clinical grounds in patients with multiple trauma
Distracting injuries
Decreased consciousness
Optimal method of intubation
Controversial
Dependent on skills of operator
Frontal impact motor vehicle accidents are associated with cervical spine injury
Cervical spine injury cannot be excluded on clinical grounds, even with normal cervical spine X-rays, due to the presence of distracting injuries or decreased consciousness
Therefore one has to assume cervical spine injury
Optimal method of intubation is controversial and dependent on skills of operator

19. Manual in-line stabilization
Decide to attempt direct laryngoscopy and therefore need manual in-line stabilization
Explain how to perform manual in-line stabilization
Stand in front of the patient and to one side
Hold mandible and occiput with both hands
Maintain neck alignment without traction or counter-traction
Illustration ©Kathy Mak, 2004

20. Intubation Rapid sequence induction
Pre-oxygenate with tight fitting face mask and 100% O2 for 3-5 minutes
Cricoid pressure
Use gum elastic bougie routinely
Explain that cricoid pressure causes subluxation of an unstable cervical spine but there is no evidence that this results in worse outcomes

21. Intubation Failed intubation You MUST have a back-up plan
LMA / Combitube / surgical airway

22. Failed intubation Anaesthetist arrives
Decides to attempt direct laryngoscopy & intubation again after bag-mask ventilation

23. Modified jaw thrust
In order to open the airway for bag-mask ventilation she performs a modified jaw thrust. Explain how to perform modified jaw thrust.
Patient is successfully and easily intubated
Illustration ©Kathy Mak, 2004

24. Intubation Trauma patients are more difficult to intubate
Do not intubate unless
you are skilled in intubation
dire emergency
Get expert help early
Remind the participants that the major indication for intubation was airway protection because of reduced consciousness and this does not constitute a dire emergency in most cases

25. Neck collar applied. Note wrong sized collar
Illustration ©Kathy Mak, 2004

26. Hypotension
BP 75/40, HR 120/min despite transfusion of 2L IV fluid and blood
300 ml drained from chest drain
Illustration ©Kathy Mak, 2004

27. Circulation Systolic BP (mmHg) >110 >100 <90 HR (bpm) >120
>140
RR (bpm) 16
16-20
21-26
>26
Mental status
Anxious
Agitated
Confused
Lethargic
Blood loss (L)
<0.75
1.5-2
>2
Estimated blood loss 30-40% of circulating volume or 1.5-2L

28. Hypotension No obvious external bleeding
Sites of occult bleeding: peritoneal cavity, pleural cavity, major fractures and retroperitoneaum
No obvious external bleeding
Illustration ©Kathy Mak, 2004

29. Hypotension
Progressive abdominal distension
Focussed abdominal sonography for trauma is operator dependent and even in trained hands is insufficiently sensitive to exclude significant intra-abdominal injury. Unexplained blood loss, abdominal distension and frontal impact motor vehicle accident make intra-abdominal bleeding very likely
-ve FAST
BP 80/40 but only with continued fluid resuscitation
Illustration ©Kathy Mak, 2004

30. Investigations CT abdomen Diagnostic peritoneal lavage Laparotomy
Contraindicated in haemodynamically unstable patients
Diagnostic peritoneal lavage
Limited utility in developed countries
Laparotomy
Options for further investigation for abdominal injury include DPL, CT abdomen and laparotomy. CT is contraindicated because of haemodynamic instability. Indications for a DPL are haemodynamic instability with unreliable clinical findings (for example due to head injury, intoxication or paraplegia) or if abdominal examination is equivocal or if repeated abdominal examination is impractical.

31. Diagnostic peritoneal lavage
Indications
Abdominal examination is equivocal (eg lower rib, lumbar spine or pelvic fractures causing abdominal tenderness and guarding) and CT is not available (e.g., developing countries)
Repeated abdominal examination impractical because of anticipated lengthy x-ray studies or GA for extra- abdominal injuries
Detects free blood in abdominal cavity with 97% accuracy

32. Diagnostic peritoneal lavage
Contraindications
Absolute: existing indication for laparotomy, including haemodynamic instability
Relative:
Pregnancy
Significant obesity
Previous abdominal surgery
In these situations (or with pelvic fractures) supra-umbilical open method should be used

33. Hypotension
Progressive abdominal distension
-ve FAST
BP 80/40 but only with continued fluid resuscitation
→ laparotomy
Focused abdominal sonography for trauma is operator dependent and even in trained hands is insufficiently sensitive to exclude significant intra-abdominal injury. In this case there is progressive abdominal distension associated with haemodynamic instability and a decision is made to progress to emergency laparotomy
Illustration ©Kathy Mak, 2004

34. Post-op intensive care
History
Mechanism of trauma
Identified injuries
Injuries that have been excluded
Operative findings
Supportive and definitive treatment
Blood loss & blood/fluid transfused
Laboratory results
Past medical history, drug allergies etc

35. Operative findings
Ruptured spleen
Splenectomy

36. ABCD
Check the position of the ETT and that it is properly secured (unlike the tube in this picture)
Illustration ©Kathy Mak, 2004

37. ABCDE Breathing Circulation Disability
Symmetrical chest movement & breath sounds
SpO2, ABG
Circulation
IV access
Appropriate monitoring
BP, HR, CVP
Disability
Level of consciousness
Limb movements
Cervical spine immobilization & logroll
Exposure and environment control
Look for other injuries and prevent hypothermia
Check both sides of the chest are moving and being adequately ventilated, SpO2, ABG
Adequate IV access, appropriate monitoring, BP, HR, CVP
Level of consciousness, limb movements, keep cervical spine immobilized until cervical spine injury excluded

38. Secondary survey Fill in the gaps
Look for problems that have become apparent with time

39. Secondary survey Scalp Eyes Maxillofacial Spine Neck Perineum
Cardiovascular
Chest
Abdomen & pelvis
Limbs
This involves a thorough head to toe examination which should include examination of the scalp, eyes, maxillofacial region, spine, neck, and perineum as well as more obvious areas such as neurological system, cardiovascular system, chest, abdomen, pelvis and limbs. The patient should be log rolled to examine the back and to perform a rectal examination.
Illustration ©Kathy Mak, 2004

40. Investigations Routine bloods Radiology ECG CT brain
Cervical spine lateral & AP, cervical CT
Pelvis XR
CXR
ECG
GCS decreased on admission, cervical spine not cleared, pelvic XR not taken in A&E.
Common for patients with pulmonary contusion to deteriorate in first hrs following injury. Not necessarily due to progression of contusion. More often due to pneumothorax, haemothorax, atelectasis, pulmonary oedema
For this reason serial CXRs are necessary in first 24 hrs ECG important in view of risk of myocardial contusion following frontal impact motor vehicle accident

41. Management Continued resuscitation Seek for and exclude other injuries
Target higher BP if haemostasis achieved
Seek for and exclude other injuries
Correct coagulopathy, acidosis, hypothermia
Treat complications
Organ failure
Distributive shock

42. Summary Methodical ABCDE approach Primary survey
Resuscitation simultaneously
Emergency surgery if required
Secondary survey
Imaging
Definitive care (OT and ICU)