Management of the Trauma Patient - Stritch School of Medicine

Management of the Trauma Patient - Stritch School of Medicine

Management of the Trauma Patient Hieu Ton-That, MD, FACS Loyola University Medical Center Division of Burns, Trauma and Surgical Critical Care Trauma in the United States 2.7 million hospital admissions per year Leading cause of death for ages 1-44 years 100,000 deaths per year from traumatic injuries Half die before they reach medical care Hemorrhage is second-leading cause of death in trauma Figure 6A: Number of Incidents by Age Number of Incidents by Age

40,000 Number of Incidents 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106 Age (years) Figure 7A: Number of Incidents by Age and

Gender Number of Incidents by Age and Gender 30,000 20,000 Males 15,000 Females 10,000 5,000 Age (years) 102

96 90 84 78 72 66 60 54 48 42

36 30 24 18 12 6 0 0 Number of Incidents 25,000 Figure 8A: Case Fatality Rate by Age

Case Fatality Rate by Age 10.0 9.0 8.0 Case Fatality Rate 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 0 10

20 30 40 Age (years) 50 60 70 80 Figure 10A: Number of Incidents by Mechanism of Injury Number of Incidents by Mechanism of Injury Number of Incidents

600,000 500,000 400,000 300,000 200,000 100,000 0 M cle hi e v or t o ffi

tra c er st th in o a g t, or ,a p y b ns ck ra

u T tr ll Fa S m ar re i F er th O Cu

ce er i t/p i ec sp d fie d an Mechanism of Injury s cla

le ab i f si P li yc c al ed er th o , st

rn bu / re Fi M ry ne i h ac Primary Survey Advanced Trauma Life Support Assess and address life threatening injuries in order ABCDE of trauma

Airway Breathing Circulation Neurologic deficit Exposure of patient Airway Identify airway obstruction Maintain cervical spine immobilization May require definitive airway Orotracheal intubation Blind nasotracheal intubation Cricothyroidotomy Tracheotomy

Breathing Identify life threatening deficits in breathing mechanism Simple pneumothorax Tension pneumothorax Massive hemothorax Open pneumothorax (sucking chest wound) Flail chest Circulation Or, identification of shock Definition of shock inadequate organ perfusion Causes of shock

Hemorrhage/hypovolemia Compressive Cardiogenic Neurogenic Sepsis Class I Class II Class III Class IV Blood Loss mL Up to 750 750-1500 1500-2000 >2000

Blood Loss % Up to 15% 15-30% 30-40% >40% Pulse rate <100 >100 >120 >140

Systolic blood pressure Normal Normal Decreased Decreased Pulse pressure Normal Decreased Decreased

Decreased Respiratory rate 14-20 20-30 30-40 >35 Urine output >30 20-30 5-15

Negligible Mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Fluid (3:1 rule) Crystalloid

Crystalloid Crystalloid and blood Crystalloid and blood Circulation Treatment of shock Direct pressure on external bleeding Initial 2 liter bolus of crystalloid fluid Responders Non-responders Transient responders Definitive management for ongoing hemorrhage

Neurologic deficit Rapid assessment of neurologic status to identify life-threatening injury Pupil size and response Mental status (Glascow coma scale) Motor and sensory exam Glascow Coma Scale 3 15 point scale to assess mental status only Best observed response Modified scale for children GCS 8 is a coma and requires intubation for airway protesction Eye opening

None = 1 To painful stimuli only = 2 To voice only = 3 Spontaneously open = 4 Verbal response None = 1 Incomprehensible sounds = 2 Incomprehensible words = 3 Confused = 4 Oriented = 5 Motor response

None = 1 Decerebrate (extension) posturing = 2 Decorticate (flexion) posturing = 3 Withdraws to pain = 4 Localizes pain = 5 Follows commands = 6 Exposure Head to toe examination of the patient for injury Pitfalls Maintenance of spine precautions Prevention of heat loss

Under cervical collar Back and flanks Adjuncts to the Primary Survey Exams during or after primary survey to aid in identifying life-threatening injuries Chest x-ray Pelvis x-ray Focused abdominal sonogram for trauma (FAST) Diagnostic peritoneal lavage (DPL) Secondary Survey and Definitive Treatment The secondary survey is a complete head to toe evaluation of the patient Adjuncts to the secondary survey include CTs, plain radiographs, blood tests Treatment plans, especially for multiple injuries, based on clinical status and

specific injuries Resuscitation Restoring organ perfusion How much is enough? What are the endpoints of resuscitation? Heart rate, blood pressure, urine output May lead to compensated shock Organ-specific indicators of perfusion ie gastric tonometry Global indicators of perfusion Lactic acid, base deficit Cardiac output, oxygen delivery, oxygen consumption Mixed venous O2 saturation (SvO2) Lactic acid and base deficit Initial BD and serum LA are reliable indicators of the need for ongoing

resuscitation Time to normalization of LA and BD are predictive of MSOF and mortality Damage-control laparotomy A shift from definitive management of abdominal injuries to stabilizing the patient for resuscitation Goals Stop bleeding Control contamination Temporary abdominal closure Critical care and rehabilitation Questions?

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