Initial Assessment and Management
Preparation o Prehospital Coordinate events with clinicians at rec hospital Airway maintenance control of external bleeding and shock immobilization immediate transport Triage o Sorting of patients based on needs for treatment and resourced available o Treatment rendered based on ABC priorities o Determine appropriate receiving facility o Multiple vs Mass casualties o Page 5. Figure 1-2 Primary Survey o ABCDE Quick assessment: ask pt to id self and ask what happened Appropriate response= no major airway compromise, breathing not severely impaired, no major decrease in level of consciousness o Airway Suction, inspect for FB, look for facial/jaw fractures Initial chin lift/jaw thrust is recommended to achieve patency All pts with GCS 50% c. 8cm reaches >90% 4. Complications: if intubate prior to decompressing, you make the tension worse. iv. Open Pneumo- cant breath because they are not able to get negative pressure, when breath in air goes through the hole. Ineffective ventilation but not affecting CO. Cant move air in a. Signs: will not have the signs of tension pneumo. No JVD. b. Treatment: i. 3-sided cover over defect. DO NOT cover it all. IF they have a hole you can create a tension pneumo. Put a chest tube 1. if have multiple holes, intubate them and give positive pressure but still cover hole ASAP.
ii. Definitive treatment: surgical c. Complications v. Flail chest/ pulmonary contusion 1. Signs: unilateral chest, chest suck in when they breath 2. Treatment: a. Initial tx includes adequate ventilation, administration of humidified oxygen, and fluid resuscitation b. supportive care, intubate as indicated; judicious fluids if hemodynamically stable be careful with fluids as the may likely have pulmonary contusion c. Analgesia can improve ventilation and prevent need for intubation vi. Massive hemorrhage/Hemothorax1. Signs a. No breath sounds and percussion dullness, flat neck veins, hemithorax may be elevated without inspiration, >1500mL blood loss b. Hemithorax: dull percussion c. Tension pneum: hyperresonant percussion 2. Treatment: a. chest decompression b. put chest tube c. Auto-transfuser d. OR if >1500mL initially or putting out at a rate of 200ml 2-4 hrs. e. If 1500ml of fluid is immediately evacuated, early thoracotomy is almost always required i. Or if less than 1500 but continue to bleed f. Indications for thoracotomy: i. Persistent need for blood; rate of blood loss and pt physiological status ii. Color of blood (arterial vs venous) is POOR indicator of necessity for thoracotomy iii. Penetrating wounds medial to nipple or scapula should alert to possible damage to major vessels iv. Only indicated if qualified surgeon is present vii. Circulation 1. PEA a. Cardiac tamponade b. Cardiac rupture c. Tension pneumothorax d. Profound hypovolemia 2. Major thoracic injuries that affect circulation that should be recognized during primary survey a. Tension pneumothorax b. Cardiac tamponade c. Massive hemothorax viii. Cardiac tamponade
1. Signs: Shock, distended neck veins, muffled heart sounds, tachycardia, low voltage EKG, late signs: pulseless electrical activity. 2. Kussmauls sign a. Rise in JVP with inspiration 3. Tests a. FAST b. Chest X-ray- see big heart c. Elevated CVP 4. Treatment: a. With a pulse: Fluids and rush to OR. b. Pulseless: Pericardiocentesis and left thoracotomy and stick foley cathereter in the hole and take to OR. c. If surgeon present → OR d. If no surgeon → pericardiocentesis (not curative) e. Pulses Paradoxus- breath in overcome tamponade and have pulse and on expiration decrease in pulse will likely go into PEA. d. Resuscitation Thoracotomy i. DO not do them in blunt trauma. ii. Patient with penetrating trauma injury arriving in PEA iii. When a surgeon with appropriate skills is present iv. Closed heart massage for cardiac arrest or PEA is ineffective in pts with hypovolemia v. No signs of life (reactive pupils, spont movements, organized ECG activity) and no electrical cardiac activity → no further resuscitative efforts needed e. Secondary Survey: Potentially Life-Threatening Injuries i. Adjunctive test; Chest X-ray, ABG, pulse oX, CT, FAST ii. Tracheobronchial tree injury 1. Often missed 2. Penetrating or blunt trauma 3. Persistent pneumo or persistent air leak 4. Bronchoscopy 5. Treatment: Decompress. Get chest tube in, if still have air leak, put in a second chest tube and make diameter as great as possible (find biggest one, 36-40) may put in a third one. airway and ventilation, tube thoracostomy, OR. iii. Simple Pneumothorax 1. Penetration or blunt trauma, if don’t treat can go into tension especially if on positive pressure ventilation, if will be on pp intubation put chest tube. iv. Hemothorax 1. Chest wall 2. Lung vessel 3. Chest tube v. Pulmonary Contusion 1. Common, will not look as bad in the initial X-ray as it will later. 2. Don’t give them more fluid than what they need. vi. Tracheobronchial Tree Injury vii. Blunt Cardiac Injury
1. Spectrum of injury 2. Abnormal EKG/monitor changes 3. Echocardiography if hemodynamic consequence. Have them on monitor in case of arrhythmia. 4. Treat: dysrhythmias Traumatic Aortic Disruption 1. Rapid acceleration/deceleration a. X-ray signs: wide mediastinum, loss of aortic notch, loss of apical pleural cap, deviation of trachea to right. Deviation of esophagus with NG tube. Scapular fractures etc. b. High index of suspicion c. Treatment: Control BP if stable, control with a drip that is short acting. d. With definitive diagnosis get Surgical consult. e. Gold standard for diagnosis is CT or angiography. f. Most do not make it alive and those that do 50% die in the hospital Traumatic Diaphragmatic Injury 1. Most often left-sided 2. Blunt: large tear 3. Penetrating: small perforation 4. Frequently misinterpreted X-ray 5. Treatment is surgery Blunt-Esophageal Rupture 1. Uncommon and difficult to diagnose a. Mechanism is severe epigastric blow b. Unexplained pain and shock c. Radiographs show mediastinal aire d. Treatment: OR Fractures and Associated Injuries- Rib, Sternum and Scapular fractures 1. Ribs 1-3 sever force, high mortality, aortic 2. Rib 4-9 pulmonary contusion, pneumo 3. Rib 10-13 intrabdominal; spleen and liver Traumatic Asphyxia 1. Signs: petechial, swelling, plethora, cerebral edema 2. Treatment: airway control and O2 Subcutaneous Emphysema. 1. Can result from airway injury, lung injury or rarely blast injury. Does not require treatment. 2. If positive-pressure ventilation is required, tube thoracostomy should be considered on the side of the subcutaneous emphysema in anticipation of tension pneumothorax developing. Pittfalls 1. Simple pneumo converts to tension pnemo 2. Retained hemothorax- complication is empyema . IF not working called a thoracic surgeon and have it cleaned. 3. Diaphragmatic injury- missed early on, persistent pain and things don’t look right reassess.
4. Inadequate pain control- big issue in patient with pulmonary contusion. And rib fractures. Consider NSAIDs and local anesthetics. 5. Extremes of age- more potential for chest injury 6. Over-resuscitation in patients with pulmonary contusion. 7. Misplaced chest tube