1. ABC’s of Multi System Trauma Christopher Freeman M.D.

2. Multi system trauma Invention of Motor Vehicles Invention of Motor Vehicles High Forces High Forces Multiple Injuries Multiple Injuries

3. Multi system trauma The most dramatic injury usually is NOT the most dangerous The most dramatic injury usually is NOT the most dangerous Primary Survey Primary Survey Secondary Survey Secondary Survey Re-evaluation Re-evaluation

4. Initial Management Airway Airway Breathing Breathing Circulation Circulation Disability Disability Exposure Exposure Correct problem before moving on Correct problem before moving on

5. Airway Assess for Patency Assess for Patency Look Look FB in Airway FB in Airway Blood/Vomit/Secretions Blood/Vomit/Secretions Listen Listen Noisy Breathing = Obstructed Breathing Noisy Breathing = Obstructed Breathing Normal speech = No Obstruction Normal speech = No Obstruction Feel Feel Tracheal Location and Midline Shift Tracheal Location and Midline Shift

6. Airway Obstruction Be Vigilant with Be Vigilant with Maxillofacial Trauma Maxillofacial Trauma Neck Trauma Neck Trauma Laryngeal Trauma Laryngeal Trauma Nonverbal Patients Nonverbal Patients

7. Airway Interventions Remove FB/Secretions/Emesis Remove FB/Secretions/Emesis Chin lift/Jaw Thrust Chin lift/Jaw Thrust Oral/Nasopharyngeal airways Oral/Nasopharyngeal airways Reassess after interventions Reassess after interventions Maintain C spine precautions Maintain C spine precautions

8. Breathing Open airway = Ventilation Open airway = Ventilation Look Look Chest rise/Symmetric movement Chest rise/Symmetric movement Listen Listen Symmetric and adequate BS/Adequate rate Symmetric and adequate BS/Adequate rate Feel Feel Crepitus Crepitus

9. Breathing Danger Signs Danger Signs Respirations <10 Respirations <10 Respirations >24 Respirations >24 Poor Chest Rise Poor Chest Rise Labored breathing Labored breathing Crepitus Crepitus

10. Breathing If inadequate ventilation/airway If inadequate ventilation/airway BVM  2>1 BVM  2>1 LMA LMA Combitube Combitube ET intubation ET intubation

11. Breathing Remember: Remember: If Adequate BVM +/- Intubating If Adequate BVM +/- Intubating All trauma patient deserve Oxygen All trauma patient deserve Oxygen Face mask is best Face mask is best Protect the Spine Protect the Spine

12. Circulation Look Look Skin Color Skin Color Listen Listen BP  Late sign BP  Late sign Level of Consciousness Level of Consciousness Feel Feel Pulse Pulse Perfusion Perfusion

13. Circulation Interventions Interventions IV  Fluids IV  Fluids Control Hemorrhage Control Hemorrhage Tourniquet  uncontrolled bleeding in unstable patient Tourniquet  uncontrolled bleeding in unstable patient Reassess after interventions Reassess after interventions

14. Disability GCS GCS APVU APVU

15. Exposure Remove from toxic exposures Remove from toxic exposures Remove wet clothing Remove wet clothing Prevent hypothermia Prevent hypothermia Expose for exam Expose for exam

16. Secondary Survey After primary  If stable After primary  If stable No Secondary  No problem No Secondary  No problem

17. Multiple Trauma Goal  Stabilize patient and transport to definitive care Goal  Stabilize patient and transport to definitive care Definitive Care unstable patient  OR Definitive Care unstable patient  OR Minimum time on scene Minimum time on scene Maximum treatment in route Maximum treatment in route Continue reassessment  ABC’s Continue reassessment  ABC’s

18. Case 1 20’s y/o M, single car MVA into tree, ejected, found on ground, unresponsive 20’s y/o M, single car MVA into tree, ejected, found on ground, unresponsive

19. Airway Look Look Blood in airway Blood in airway Listen Listen Gurgling Gurgling Feel Feel Midline trachea Midline trachea

20. Airway Intervention Suction Suction Jaw thrust/Chin lift Jaw thrust/Chin lift Reassessment Reassessment Clear respirations, No FB present in airway Clear respirations, No FB present in airway

21. Breathing Look Look Symmetric, adequate chest rise, no paradoxical movement Symmetric, adequate chest rise, no paradoxical movement Listen Listen Rate 20, equal BS B/L Rate 20, equal BS B/L Feel Feel Crepitus over L chest Wall Crepitus over L chest Wall

22. Breathing Intervention ??? ??? Crepitus  No respiratory distress Crepitus  No respiratory distress

23. Circulation Look Look Pale, no obvious bleeding Pale, no obvious bleeding Listen Listen 100/60, Arousable to stimuli 100/60, Arousable to stimuli Feel Feel HR 130’s, Cool to touch HR 130’s, Cool to touch

24. Circulation Intervention Place 2 Large bore IV Place 2 Large bore IV Bolus 2 L NS Bolus 2 L NS Reassess Vitals Reassess Vitals

25. Disability GCS GCS Eyes 2 Eyes 2 Verbal 3 Verbal 3 Motor 5 Motor 5 Total 10 Total 10

26. Exposure Wet clothes removed Wet clothes removed No obvious limb injury No obvious limb injury Blanket applied Blanket applied

27. Reassessment Airway Airway Gurgling  Suction with improvement Gurgling  Suction with improvement Breathing Breathing RR 34, Decreased BS on L, L sided Crepitus… RR 34, Decreased BS on L, L sided Crepitus…

28. Diagnosis Tension Pneumothorax Tension Pneumothorax

29. Breathing Intervention Needle Decompression L chest Wall Needle Decompression L chest Wall

30. Reassessment Airway Airway Clear, no gurgling, trachea midline Clear, no gurgling, trachea midline Breathing Breathing RR 20, Equal chest expansion, good chest wall rise RR 20, Equal chest expansion, good chest wall rise Needle 2 nd intercostal space midclavicular line Needle 2 nd intercostal space midclavicular line Circulation Circulation HR 110, BP 110/70, Skin Warm/Well perfused HR 110, BP 110/70, Skin Warm/Well perfused

31. Secondary Survey Blah, Blah, Blah Blah, Blah, Blah

32. Disposition To ED, Stable To ED, Stable Admitted Admitted Concussion Concussion R CT, PTX/HTX R CT, PTX/HTX Grade 3 liver laceration Grade 3 liver laceration D/c from hospital 1 week later D/c from hospital 1 week later

33. Case 2 27 Y/O MCA into Car 27 Y/O MCA into Car Unhelmeted, thrown from vehicle Unhelmeted, thrown from vehicle Found on ground Found on ground Bystander called EMS Bystander called EMS

34. Airway Look Look Blood in airway Blood in airway Listen Listen Gurgling respiration Gurgling respiration Feel Feel Midline trachea Midline trachea

35. Airway Intervention Suction Suction Jaw thrust/Chin lift Jaw thrust/Chin lift Oropharengeal Airway placed Oropharengeal Airway placed Reassessment Reassessment Quiet, No FB present in airway Quiet, No FB present in airway

36. Breathing Look Look Symmetric, Poor chest rise, no paradoxical movement Symmetric, Poor chest rise, no paradoxical movement Listen Listen Rate 6, diminished BS B/L Rate 6, diminished BS B/L Feel Feel Crepitus over B/L chest Wall Crepitus over B/L chest Wall

37. Breathing Intervention BVM BVM

38. Breathing Reassessment Look Look Symmetric, Poor chest rise, no paradoxical movement Symmetric, Poor chest rise, no paradoxical movement Listen Listen Rate 18 by BVM, diminished BS B/L Rate 18 by BVM, diminished BS B/L Feel Feel Crepitus over B/L chest Wall Crepitus over B/L chest Wall

39. Breathing Intervention B/L Needle Decompression B/L Needle Decompression

40. Breathing Reassessment Look Look Symmetric, Adequate chest rise, no paradoxical movement Symmetric, Adequate chest rise, no paradoxical movement Listen Listen Rate 20 by BVM, equal BS B/L Rate 20 by BVM, equal BS B/L Feel Feel Crepitus over B/L chest Wall Crepitus over B/L chest Wall

41. Circulation Look Look Pale, Bleeding from LLE, LUE Pale, Bleeding from LLE, LUE Listen Listen 80/50, unconscious, unarousable 80/50, unconscious, unarousable Feel Feel HR 140’s, Cool to touch HR 140’s, Cool to touch

42. Circulation Intervention Place 2 Large bore IV Place 2 Large bore IV Bolus 2 L NS Bolus 2 L NS Pressure on bleeding sites Pressure on bleeding sites Reassess Vitals Reassess Vitals

43. Circulation Reassessment Look Look Pale, Persistent bleeding LLE, Bleeding controlled LUE Pale, Persistent bleeding LLE, Bleeding controlled LUE Listen Listen 80/50, unconscious, unarousable 80/50, unconscious, unarousable Feel Feel HR 150’s, Cool to touch HR 150’s, Cool to touch

44. Circulation Intervention Tourniquet to LLE Tourniquet to LLE

45. Disability GCS GCS Eyes 1 Eyes 1 Verbal 2 Verbal 2 Motor 4 Motor 4 Total 7 Total 7

46. Exposure Wet clothes removed Wet clothes removed Limb deformity, Bleeding LUE, LLE Limb deformity, Bleeding LUE, LLE Blanket applied Blanket applied

47. Reassessment Airway Airway Oropharngeal Airway in place, No FB Oropharngeal Airway in place, No FB Breathing Breathing RR 20, Decreased BS on B/L, Increased Airway resistance RR 20, Decreased BS on B/L, Increased Airway resistance

48. Intervention Chin Lift/ Jaw Thrust Chin Lift/ Jaw Thrust Oral Suction Oral Suction Needle decompression Needle decompression

49. Reassessment Airway Airway Oropharngeal Airway in place, No FB Oropharngeal Airway in place, No FB Breathing Breathing RR 20, Equal BS on B/L, Normal resistance RR 20, Equal BS on B/L, Normal resistance Circulation Circulation HR 120’s, BP 90/50, Bleeding controlled with tourniquet HR 120’s, BP 90/50, Bleeding controlled with tourniquet

50. Secondary Survey Not Done prior to arrival Not Done prior to arrival

51. Disposition To ED, Unstable To ED, Unstable Arrest In ED Arrest In ED ED Thoracotomy  Unsuccessful ED Thoracotomy  Unsuccessful

52. Summary Keep it Simple Keep it Simple ABC’s ABC’s Airway Management = Intubation Airway Management = Intubation Minimize time to Definitive treatment  OR Minimize time to Definitive treatment  OR

53. Questions?