Trauma

Initial survey (the ABCs), shock in the nontrauma setting, a review from head to toe, burns, bites and stings.

If the patient is unconscious or their voice is not normal…

they need an airway.

If the patient is conscious and their voice is normal but they have an expanding hematoma in the neck or subcutaneous emphysema in the neck or the upper chest…

they need an airway.

Expanding hematoma in the neck

Rapid aenesthetic induction with pulse oximetry and oro-/naso- tracheal intubation.

Subcutaneous emphysema in the neck or the upper chest

Fibreoptic intubation due to possible bronchial tree injury.

Intubation of an unconscious patient with a suspected spinal cord injury

Fibreoptic naso-/oro- tracheal intubation without moving the neck.

Intubation when the naso/oro pharynx is inaccessible, etc. major facial trauma, anaphylactic shock

Cricothyroidotomy (not tracheostomy, done to a patient who already has an airway).

Also percutaneous catheter into the trachea with high-frequency ventilation (contraindicated with head injury).

If a patient is not breathing spontaneously, doesn’t have bilateral breath sounds or his pulse oximetry is abnormal

the patient needs assisted breathing.

Immediate shock parameters in a trauma patient

ABP < 90 mm Hg and poor quality, fast pulse.

Diaphoretic, cold, shivering, anxious.

Common types of shock in the trauma setting

1. hypovolemic hemorrhagic

2. pericardial tamponade

3. tension pneumothorax.

For the latter two, the chest has to be included in the trauma. May not be obvious with blunt trauma.

Signs of pericardial tamponade or tension pneumothorax

Trauma to the chest, signs of shock, and distended neck and facial veins (CVP > 20-25 mm Hg).

Signs of hypovolemic hemorrhagic shock

Trauma, signs of shock and empty neck and facial veins (CVP < 2 mm Hg).

Difference between pericardial tamponade and tension penumothorax

Tension pneumothorax causes dyspnea, unilateral breath sounds, hyperressonance on percussion and mediastinal shift.

Management of hemorrhagic shock

1. if at all possible stopping the source of bleeding*

2. filling the vascular tree.

*Patient has to be close to a trauma center, the source of bleeding must be located.

Control of bleeding from an extremity

Direct pressure.