Life-threatening injuries

In the time following a major trauma, at what 3 points is the patient most likely to die?

1. At the time of the trauma.These patients usually can’t be saved as their death is instantaneous, or their injuries are unsurvivable.

2. 1-2 hours later. These patients are the ones who initially compensated for trauma, (eg. increasing HR, shutting off peripheral circulation etc.) but have now used up their physiological reserves.

3. Weeks later. This is when patients experience sequelae of trauma such as infection and multi-organ failure.

The ‘golden hour’

The first 60 minutes after a major trauma that determines a patient’s outcome. Advanced Trauma Life Support (ATLS) targets patients in this hour.

ATLS Assessment map

ABCDE - gives priority to injuries and problems that will kill a patient quickest.

ABCDE

Airways

Breathing

Circulation

Disability

Exposure

Assessing airways

• Can they respond?

• Gurgling, wheezes and snoring noises are more worrying

• Examine the patient’s face, mouth and nose - severe injuries and physical blockages can put the airway at risk.

How to open blocked airways

• Suctioning fluids

• Remove any foreign bodies

• Basic airway manoeuvres (lift chin)

• Airway adjuncts

• High flow O2

What should all trauma patients get?

• High flow O2

• C-Spine control

What does this radiograph show?

Fracture of the dens on the second cervical vertebra. This injury is quite common in high energy trauma, so every patient should be assumed to have a cervical fracture and get C-spine care until proven otherwise.

What are the two main issues with breathing in trauma patients?

• Lung cavity fills with something else (usually air or blood)

• Thoracic cage is damaged

Tension pneumothorax typical mechanism (open)

Penetrating trauma makes a hole in the chest wall, allowing air to be drawn into the thoracic cavity when the patient breathes in, and sealing shut when the patient breathes out. Every time the patient breathes in, more air enters, collapsing the lung and increasing the pressure inside.

What happens as pressure rises in a patient’s thoracic cavity (tension pneumothorax)?

• The mediastinum is pushed over to the other side, squashing the remaining lung and further compromising breathing.

• Venous return will reduce as the pressure becomes equal to the pressure in the great veins of the heart, eventually causing heart arrest.

How to spot a tension pneumothorax

• Decreased breath sounds on one side.

• Increased percussion note (hyperresonant)

• Engorged neck veins

• Reduced lung expansion

• Deviation of trachea to opposite side

Why should you never see a radiograph that looks like this?

A tension pneumothorax this severe will have all clinical signs present, so treatment should not be delayed for a radiograph.

Treatment of a tension pneumothorax

• High flow oxygen

• Needle decompression - only a temporary measure

• Chest drain insertion within 30 mins

Needle decompression

Insertion of a large bore needle through the chest wall to allow air from the thoracic cavity to escape.

Where is needle decompression done?

• Adults: 4th or 5th intercostal space at the mid-axillary line (a line from the middle of the armpit). Same location as chest drain insertion.

• Children: 2nd intercostal space (below 2nd rib), in line with the middle of the clavicle.

Open pneumothorax

When the patient breathes in, air enters the thoracic cavity via their wound and bypasses the lungs entirely. When the patient breathes out, the air is forced out again via the wound.

Air enters the thoracic cavity via the path of…

least resistance

What are the consequences of an open pneumothorax?

The blood is not oxygenated properly because there is a lack of effective breathing.

Treatment of an open pneumothorax

• High flow O2

• Place a 3 sided dressing over the wound to create a makeshift external one-way valve.

• Chest drain insertion.

What conditions commonly affect the breathing of trauma patients?

• Tension pneumothorax

• Open pneumothorax

• Massive haemothorax

• Flail chest

Flail chest

Two or more ribs fractured in 2 or more places, leading to a separation of a segment of the thoracic cage. When the patient breathes in, this floating fragment is drawn inwards, while the rest of the ribcage moves out. This prevents effective ventilation. There are often also underlying injuries to the lungs (eg. haemopneumothorax and contusions)

Treatment of flail chest

Fix the fracture with a plate and screws. This relieves pain, allows the patient to recover faster and reduces lung problems like chest infections.

Signs of circulatory compromise

• Pale

• Poor peripheral circulation

• Heart sounds

• Look at observation readings like pulse and blood pressure

Initial actions to treat circulatory compromise

• Establish two cannulas for IV access. This allows rapid fluid resuscitation.

• Control obvious source. Eg. apply external pressure to a bleeding wound, use a pelvic binder

What are the two main issues with circulation in trauma patients?

• Haemorrhagic conditions

• Cardiogenic issues

Common haemmorhagic conditions in trauma patients

• Pelvic fractures

• Massive haemothorax

Pelvic fractures

These fractures can result in massive blood loss into the pelvic cavity, which may not be immediately obvious. Using a pelvic binder can slow the internal bleeding.

Massive haemothorax

This occurs when 1500 mls of blood is lost into the pleural cavity. This prevents the lungs from inflating fully.

Treatment of massive haemothorax

Insert a chest drain, and provide blood products. Cardiothoracic surgery is then performed.

Common cardiogenic issue in trauma patients

Cardiac tamponade

Cardiac tamponade

Compression of the heart by an accumulation of fluid in the pericardial sac. This sac is ‘fixed’ (like the skull), meaning even a small pressure increase has a big effect. The heart then cannot pump during systole, or dilate to fill during diastole.

Treatment of cardiac tamponade

Pericardiocentesis - US guided needle enters the chest wall and punctures the pericardium to extract the blood gathered there.

Presentation of cardiac tamponade

• History of penetrative trauma to thorax

• Becks triad:

  • Hypotension: decreased stroke volume

  • Jugular venous distension: impaired venous return to the heart

  • Muffled heart noises: fluid inside the pericardium

What is the usual outcome of having any of these life threatening conditions?

The patient goes into shock.

Shock

End-organ dysfunction due to inadequate oxygen availability for tissues (perfusion).

What type of tissues are worst affected by shock?

Oxygen sensitive tissues like cardiac, gut, brain and renal tissues etc.

What are the two main causes of shock?

• Reduced delivery of O2 (restricted blood vessels, inability for blood to pump, loss of blood…)

• Increased demand for oxygen

Lethal triad of trauma

• Acidosis

• Hypothermia

• Coagulopathy

How can trauma lead to acidosis?

If there is inadequate oxygen availability, the organs keep functioning in the absence of it using non-aerobic respiration. This leads to metabolic acidosis.

What is the most common type of shock in trauma patients?

Haemorrhagic shock

What are the 5 most common places for major blood loss in trauma patients?

• Intrathoracic cavity

• Intraperitoneal cavity

• Retroperitoneal space

• Thigh compartments

• Floor

What are the 4 classes of haemorrhagic shock?

• Class i - <15% (roughly <750ml), <100 bpm, normal BP, urine output = >30 ml/hr

• Class ii - 15-30% (roughly 750-1500 ml), 100-120 bpm, normal BP, urine output = 20-30ml/hr

• Class iii - 30-40% (roughly 1500-2000ml), 120-140 bpm, BP dropping, urine output = 5-15 ml/h

• Class iv - >40% (roughly >2000 ml), >140 bpm, BP dropping, urine output = negligable

What happens to urine output as patients go into shock?

It begins to drop

What happens to heart rate as patients go into shock?

It increases

What will happen to the patients blood pressure when they go into the later stages of shock?

It will drop.

Why is a low blood pressure for shock patients good (permissive hypotension)?

It is just enough to keep cerebral perfusion, but not enough to start bleeding again. 80mmHg systolic pressure is the rough target.

Fluid resuscitation

• First stop bleeding

• Provide blood products: red blood cells, platelets and fresh frozen plasma

• Tranexamic acid - promotes clotting

• Permissive hypotension

Disability

Level of consciousness

What is the best way to assess disability?

The Glasgow Coma Scale (GCS) - Gives the patient a score out of 15. The higher the score, the more alert the patient is.

What is a quick way to assess disability (not GCS)?

Alert, Verbal, Pain, or Unresponsive (AVPU) scale

What are the two most common reversible reasons for unconsciousness?

Temperature and blood glucose.

Exposure

Full exam of patient whilst keeping them warm.

Why is it important to keep trauma patients warm?

Clotting is temperature dependant.

Common sites to miss injuries

• Back of head

• Back

• Buttocks

• Perineum

• Axillae (armpits)

• Skin folds

If anything changes during the ABCDE assessment, what should you do?

Go back and reassess!

Mnemonic to remember life threatening trauma conditions

ATOM FC

ATOM FC

Airway obstruction

Tension pneumothorax

Open pneumothorax

Massive haemothorax

Flail chest

Cardiac tamponade

Secondary survey

Systematic examination with log roll, usually done by an orthopaedic registrar.