EMST / ATLS

Background

 

Trauma is 3rd most common cause death in all age groups

- number one in young adults < 44 years


Death

 

Death occurs in 3 time periods

 

1.  First few minutes

- death secondary aortic rupture or severe head injury

- 50% die in this period

- only a few survive 

- only if rapid transport 

 

2. Golden Hour 

- major head injury (Haematoma)

- chest injury (Pneumothorax)

- abdominal injuries (Ruptured viscus)

- major fracture (Pelvis, Long bone)

- 35% of deaths

- high salvage rate

 

3. Late death

- days to weeks later 

- brain death / multiorgan failure / sepsis

 

Management priorities

 

1.  Life threatening injuries

2.  Limb threatening injuries

 

Assessment & Management

 

1. Preparation

A Pre-hospital

B In-hospital

2. Triage

3. 1° Survey

4. Resuscitation

5. 2° Survey

6. Continue post resuscitation monitoring & re-evaluation

7. Definitive Care

 

Can occur simultaneously or parallel

 

Preparation

 

A. Pre-hospital

 

Co-ordination between Ambulance & hospital

 

Aims

1. Airway control

2. Stop bleeding

3. Immobilize patient

4. Rapid transport to appropriate facility

5. Obtain history

 

B. In-hospital

 

1. Prepare trauma area

- 1 nurse to take observations on arrival and every 2 minutes

- 1 nurse to record

- cannulas / IDC / chest tube

- suction / intubation

 

2. Notify trauma team

- general surgery / cardiothoracic aware and available

- anaethetist aware and available

 

3. Notify lab

- O negative blood available

- ready to process emergency blood tests / cross match

 

4.  Radiology

- technician to take C spine / CXR / pelvis

 

Triage

 

Sorting of patients based on treatment needs

 

Two scenarios

 

Multiple

- patients don't exceed treatment maximum of hospital 

- treat life threatening pathology first

 

Mass

- patients exceed treatment maximum of hospital

- treat those who will survive if simple intervention

 

Primary survey

 

Life threatening conditions are diagnosed and treated simultaneously

 

A.  Airway Maintenance and Spinal Precautions   

 

A patient who can respond verbally to "How are you?" is conscious and has a clear airway

 

Assume spinal fracture

- hard cervical collar with sand bags and tape

- spinal board

- log roll

 

Monitoring / 2 x large bore 16G cannulas / bloods

- simultaneously attached

- 02 / ECG / blood pressure

- CBC / Renal and liver function / coags / Group and hold / cross match / BHCG

 

Immediate management

- jaw thrust and chin lift

- clear FB / blood etc

- apply oxygen

 

Indications intubation

- GCS < 8

- maxillofacial fractures

- laryngeal trauma / stridor

 

Intubation Adult

- guedel airway / preoxygenate 100% oxygen

- inline traction / protect spine at all times

- rapid sequence induction / cricoid pressure

- xylocaine spray 10%

- fetanyl (1 mcg / kg, 50 - 100 mcg)

- midazolam (0.05 - 0.1 mg / kg, 5 - 10 mg)

- avoid muscle relaxants if possible (succinylcholine 1 mg / kg, usually 100mg)

- avoid propofol if possible / causes hypotension (10mg / ml, give 2.5 mg / kg to maximum 250 mg)

 

Intubation Paediatric Patient

- use Broselow Paediatic Emergency Tape for weight and medications based on heights

- preoxygenate

- atropine 0.02mg / kg or 0.1 to 1 mg given 2 minutes before intubation

- this prevents excessive vagal response and dries secretion

- sedate midazolam 0.1 - 0.3 mg / kg

- cricoid pressure

- paralyse succinylcholine 2mg / kg < 10 or 1 mg / kg > 10

- ETT based on size little finger

- trachea short (5 - 7cm in infant) and very anterior

- set tidal volumes at 6 - 8 ml / kg and RR 40/min infant and 20/min older child

 

Unable to intubate

 

1.  Jet insufflation cricothyroidotomy

- prep / LA

- small incision often required

- insert 12 or 14 G plastic cannula through cricothyroid membrane

- attach to syringe / angle 45o caudal

- aspirate as insert / stop when aspirate air / advance cannula over needle

- connect to 15 L minute oxygen

- have Y connector or cut side hole in tubing

- intermittitent insufflation 1 second on and 4 seconds off with thumb over hole

- suitable for 30 minutes

 

2.  Surgical cricothyroidotomy

- prep / LA

- horizontal incision between thyroid and cricoid cartilage

- horizontal incision between thyroid and cricoid / don't cut either cartilage

- open with artery forceps

- insert size 5, 6 or ETT, inflate and secure

- not suitable in children under 12 as cricoid is very important

 

Gastric distention / NGT

- can cause hypotension or aspiration

- very common in trauma / children / forced ventilate with bag and mask

- insert NGT as soon as able

- insert through mouth if facial trauma / avoids intracranial penetration

 

B.  Breathing  

 

Immediate management

 

Apply oxygen

- 12 L/min

- check RR (> 20 / minute worrying)

- check oxygen saturations

- apply ECG monitoring

 

Examination

 

Expose chest

- look / feel for flail segment

- symmetrical motion

 

Auscultate

- symmetrical breath sounds

- hear sounds

 

Palpate

- trachea midline

- heart apex

- rib fractures

 

Diagnosis

 

Pneumothorax / haemothorax

- decreased breath sounds

 

Hemothorax

 

Tension pneumothorax

- heart apex and trachea displaced

- heart sounds (muffled + distended neck veins = cardiac tamponade)

 

Tension Pneumothorax / Needle thoracostomy

- second intercostal space in midclavicular line

- large gauge needle / 16G

- will hear hiss if tension

- need to place ICC

 

Pneumothorax / Hemothorax / Intercostal Catheter

- 5th intercostal space just anterior to midaxillary line

- need to avoid spleen / liver

- level with nipple

- use larger tube if for haemothorax

- gown and glove, prep, LA down to pleura

- scapel incision, artery forcep down through pleura

- blunt dissection

- insert 32 F gauge tube without stylet aiming posteriorly and superiorly

- connect to underwater suction drain at -20 cm H2O

- suture and tape in (no 1 suture purse string, standard dressing, sleek)

- ensure drain is swinging

 

PneumothoraxPneumothorax Post ICC

 

Open chest wound

- taped on 3 side flutter dressing intially

- allows air out with expiration

- convert to occlusive dressing only after insertion of ICC

- ICC in 5th intercostal space

- otherwise risk tension pneumothorax

 

Cardiac Tamponade / Pericardiocentesis

- 20 ml syringe and 18G spinal needle

- aseptic technique

- insertion point between xiphisternum and left sternocostal margin

- can fill with some saline and inject 1ml periodically to prevent blockage of tip

- angle 45o to abdominal wall, 45o to sagittal plane

- aim for tip of left scapula

- insert up to 5 cm watching for ECG changes, aspirating as advance

- if patient truly has cardiac tamponage, insert drainage catheter using seldinger technique

- best done under echo guidance if possible

 

Hemothorax / Indications for thoracotomy

- > 1500 mls blood

- > 250 mls per hour for 4 hours

 

Flail chest

- no specific management required

- management of underlying lung injury

- may require mechanical ventilation / epidural

 

C. Circulation

 

Stages of Shock

 

  Stage I Stage II Stage III Stage III
Blood loss < 750 750 - 2000 1500  - 2000 > 2000
% blood volume 15% 30% 40% > 40%
PR < 100 > 100 > 120 > 140
BP Normal Decreased < 90 < 70
Pulse Pressure Normal Decreased    
RR Normal   30 - 40 > 35
Urine output > 30 Slightly reduced   Negligible
GCS Anxious Anxious Confused Lethargic

 

Immediate Management

 

Stop external bleeding / pressure

IV cannulas x2 16G         

Send off FBC / ELFT / glucose / Toxicology / Xmatch / pregnancy test

 

Resuscitate with isotonic crystalloid

- 2 litres then

- blood (O negative / type specific / cross matched)

 

Children 20 mls / kg bolus

- repeat x 3 then consider blood

- blood 10mls / kg type specific or O negative

- any hypotension in child indicates severe blood loss / > 45%

- can provide via intraosseous tibial infusion in < 6 hours

- anteromedial tibia below tibial tubercule / aim away from knee

- maintenance 4 / 2 / 1 rule per hour

 

Burns

- rule of 9's to calculate % BSA

- 2 - 4 mls RL per kg per % BSA first 24 hours

- half in first 8 hours, remainder in last 16 hours

 

Pelvic immobiliser / strap / sheet if any signs pelvic injury

 

ECG

- premature ventricular contractures

- lidocaine 1 mg / kg

 

Causes

 

Lung - tension pneumothorax / hemothorax

Heart - cardiac tamponade / aortic dissection

Abdomen - intra-abdominal bleeding

Pelvis - pelvic fractures

Long bone fracture

Spinal injury

External bleeding

Corticosteroid deficiency

 

Examine

- signs chest trauma / reduced breath sounds

- muffled heart sounds / distended neck veins

- abdomen exam - tenderness / rigidity

- pelvis - tender / mobile

- femoral deformity / long bone fracture

- external bleeding / scalp laceration

 

Investigations

- abdomen (Fast scan / DPL / CT scan) 

- pelvis (Xray)

- CXR (hemothorax / widened mediastinum)

- echo / CT chest

 

DPL

 

Technique

- LA

- decompress bladder with IDC

- decompress stomach with NGT

- incision supraumbilical if pelvic fracture / infraumbilical otherwise

- dissect down to peritoneum

- insert peritoneal dialysis catheter and aspirate

- if aspirate negative, infuse 1L crystalloid

- lavage , then aspirate 250 mls

- send to lab for analysis

 

Results

1.  Initial aspiration

- > 10 mls frank blood or obvious bowel contents

2.  Post lavage

- labs analysis: > 100 000 RBCs or > 500 WBC / ml, or positive gram stain

 

Hypotensive / Bradycardia

- suspect spinal injury

- trial 2L fluid

- atropine: 0.5 - 1 mg IV as push / maximum 3 mg

- noradrenalin: 0.1 - 2 mcg / kg / min up to maximum 30 mcg/min

- dopamine: 10 mcg / kg / min

 

IDC
- as soon as patient stable enough

- enables monitoring of resuscitation

- adults 0.5 mls / kg / hour

- paeds 1 ml / kg / hr (2mls if < 1 year)

 

D.  Disability 

 

GCS / Pupils

 

GCS = MVE

Severe HI <9

Moderate HI 9-12

Minor 13-15

 

Best eye response (E)

1. No eye opening 

2. Eye opening in response to pain

3. Eye opening to speech

4. Eyes opening spontaneously 

 

Best verbal response (V)

1. No verbal response 

2. Incomprehensible sounds

3. Inappropriate words

4. Confused

5. Oriented

 

Best motor response (M)

1. No motor response 

2. Extension to pain

3. Abnormal / decorticate flexion to pain

4. Normal flexion / Withdrawal to pain

5. Localizes to pain

6. Obeys commands

 

Head Injury < 9

 

Intubate

CT Head

Neurosurgery consult

Oxygenate

Avoid hypotension

Maintain low ICP

 

Low ICP

 

Maintain BP

- avoid glucose containing fluids

- Ringer's lactate or N/S

 

Hyperventilation

- low CO2 can cuase cerebral ischaemia

- keep CO2 at 35 mmHg

- can lower CO2 to 30 mmHg in acute deterioration

 

20% Mannitol

- indicated for acute neurological deterioration in patient without hypotension

- 1g / kg IV as bolus over 5 minutes

 

Seizures

 

Diazepam 0.2 mg / kg at rate 5 mg / minute

- so maximum dose 20 mg in 100 kg man

 

Phenytoin

- loading dose 1g IV at 50mg / minute

- maintenance dose then 100 mg / 8 hours

- titrate based on serum levels

 

E.  Exposure   

 

Suitably undress

Avoid hypothermia / keep warm

 

Do not proceed to Secondary Survey until stable

 

Early monitoring 

- PR / BP

- O2 sats

- arterial line

- NGT / IDC - if no CI

 

Trauma Series    

- lateral C spine / CXR / AP pelvis

 

Blood at meatus / high riding prostate / suspected urethral disruption

- urethrogram / 15 mls contrast via IDC in urethral meatus with balloon minimally inflated

- if urethra intact on xray / advance into bladder

- inflate with 1500mls contrast / saline and leave balloon inflated

- looking for bladder injury

- extraperitoneal - IDC left in situ draining

- intraperitoneal - requires surgery

- if urethra not intact requires urology intervention / surgery

 

Secondary survey

 

Meticulous examination from head to toe encompassing all systems looking for occult injury

 

History

 

Get ancillary history        

- ambulance officers / police / Family / Patient / Witnesses

 

Allergies

Medications

Past medical history

Last ate

Events related to accident         

- MOI / Restraint / Ejection

 

Head to toe

 

Scalp - lacerations / open fractures

Eyes  - pupils

Face - fractures

Mouth

C spine    

- tender

- step / gap / boggy swelling

- ROM if conscious and co-operative / no distracting injuries

 

Neck 

- subcutaneous emphysema

- lacerations

- tracheal deviation

- oesophageal injury

- vessel injury

 

Chest

- breath Sounds

- heart Sounds

- subcutaneous emphysema

- ribs / sternum / clavicle fracture

 

Abdomen 

- distension

- tenderness

 

Pelvis     

- spring test

- push / pull test

- tenderness / ecchymosis

- blood meatus / scrotal ecchymosis / open injuries (rectum / vagina) / high riding prostate

 

UL   

- shoulder girdle and clavicle / SC jts

- long bones

- dislocations

- neurovascular

- compartments

 

LL   

- long bones

- dislocations

- neurovascular

- compartments

 

Spine logroll

- step / gap / boggy swelling / tender / ecchymosis

- PR -  tone / power / sensation / BCR / anal wink reflex