Weel 6 Trauma ABCDs: Part I Assessment and management

Airway

Management of the airway is paramount in the successful resuscitation of the trauma patient. 

Without a patent airway, all is lost. 

However, the best airway for a particular patient may not be an advanced airway or endotracheal tube.

Upper anatomy of airway

Pediatric Considerations

• Larger head and tongue

  • Special attention to positioning

  • Greater potential for airway obstruction

• Trachea

  • Shorter and conical shape

  • Epiglottis

  • Proportionally larger

  • Floppier than adults’

Assessment

• If the patient is talking, airway is open.

• Look for:

  • Blood

  • Broken teeth

  • Foreign bodies

  • Vomitus

  • Hematomas 

• Listen for:

  • Snoring

  • Stridor (inspiratory) 

  • Gurgling (expiratory)

  • Hoarseness

• Feel for:

  • Crepitus in the neck - crunchy bones

• Oxygen saturation

Injury and Dysfunction

• Partial obstruction–some passage of air

• Total obstruction–no passage of air

  • Common causes of obstructions

    • Tongue

    • Foreign body

    • Blood, vomit, teeth

Direct Trauma

• Blunt

  • Swelling and edema 

  • Fractured larynx

  • Crepitus (subcutaneous emphysema)

  • Hematoma 

• Penetrating

  • Bleeding into the airway

  • Crepitus (subcutaneous emphysema)

  • Hematoma

Airway Management

• The goal in managing any patient’s airway is to maintain an open and patent airway that allows for adequate breathing, ventilation, and oxygenation.

• Management progresses from basic to more advanced procedures and adjuncts.

Breathing, Ventilation, and Oxygen

Anatomy

Anatomy

Assessment

• If the patient’s breathing draws your attention, there is a problem until proven otherwise.

• Some examples would be:

  • If you can hear them breathing from across the room

• If they position themselves for easier breathing

• Tripoding

Assessment

• Look (observe)

• Listen (auscultate)

• Feel (palpate)

Pneumothorax

• Present in up to 20% of severe chest injuries

• Classified as simple, open, or tension

• May progress from a simple to a tension

  • Tension pneumothorax is life-threatening.

  • Needle decompression may be needed.

• May be associated with a hemothorax

Simple versus Tension Pneumothorax

• Simple

  • Blunt or penetrating

  • BS decreased or absent

  • Mild to moderate ventilatory distress

• Tension

  • Blunt or penetrating

  • BS decreased or absent

  • Marked ventilatory distress

  • Hemodynamic compromise

Assessment and Diagnosis

Open Pnuemothorax

Flail Chest

Simple Rib Fractures

• Most common thoracic injury

• Usually in ribs 4 through 8, laterally

• Most common cause of hemothorax 

• Simple rib fractures may be associated with injuries to liver and spleen.

• Common complaints are chest pain and shortness of breath.

Management Goals

• The goal of the treatment of injuries that affect breathing is to maintain adequate oxygenation and ventilation.

  • Administer supplemental oxygen, PRN.

  • Assist ventilations as necessary .

  • Seal open chest wounds.

  • Recognize and decompress tension pneumothorax.

• Continuous assessment of breathing is essential.

When to Assist Ventilations

• Respiratory rate, AND inadequate

  • More than 28 

  • Fewer than 10

• Insufficient spontaneous tidal volume

  • Poor chest rise

  • Use of accessory muscles

• Decreased SaO₂

• Consider the need for airway management.

Circulation and Hemorrhage and Shock

Metabolism

• All cells require energy to function, and that energy is stored in the form of ATP molecules.

• Aerobic metabolism

  • Oxygen is required for efficient production of ATP (energy).

• Anaerobic metabolism

  • Inadequate oxygen results in decreased ATP production and accumulation of lactic acid.

Shock

•  Shock is a result of inadequate energy production to sustain life.

• Any condition that causes generalized cellular hypoperfusion

• This leads to inadequate cellular oxygenation that does not meet metabolic needs.

Hypoperfusion

• Hypoperfusion results from:

  • Loss of blood (either externally or internally)

  • Impaired pumping of blood

  • Dilatation of the blood vessels (increased vascular space)

• The end result is a decrease in circulating volume and RBCs moving through the capillary beds to deliver oxygen to the cells.

• Lack of oxygen impairs metabolism.

• ATP (energy) production decreases.

• Cell membrane dysfunction occurs.

  • Potassium and lactic acid enter the blood.

    • Low pH results in release of cellular enzymes that autodigest cells.

    • Autodigestion leads to cellular death and organ failure.

  • Sodium and water enter the cell.

    • Cellular edema (swelling) occurs.

    • INFLAMMATION

    • There is a further loss of intravascular (blood) volume

  • The cycle continues.

• Consequences

  • With inadequate ATP, the patient does not produce heat.

    • Body heat is lost to the environment.

    • What little ATP is being produced is used to shiver.

      • Lactic acid production increases.

    • As body temperature drops, blood clotting becomes impaired and hemorrhage can increase.

    • Cells and organs do not function properly.

Organ Tolerance to Hypoxia

• Brain 4 to 6 minutes

• Heart 4 to 6 minutes

• Lungs 4 to 6 minutes

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• Kidneys 45 to 90 minutes

• Liver 45 to 90 minutes

• Gastrointestinal tract 45 to 90 minutes

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• Muscle 4 to 6 hours

• Bone 4 to 6 hours

• Skin 4 to 6 hours

Hypovolemic Shock

• The most common cause of shock in the trauma patient

  • Due to hemorrhage

    • Loss of RBCs impairs oxygen transportation

  • In any trauma patient with shock, assume hemorrhage is the cause until proven otherwise.

Distributive Shock

• Distributive

  • Neurogenic

    • Decreased systemic vascular resistance due to vasodilatio

Cardiogenic Shock

• Cardiogenic (in trauma)

  • Intrinsic

    • Blunt cardiac trauma leading to muscle damage and/or dysrhythmia

    • Valvular disruption

  • Extrinsic

    • Pericardial tamponade

    • Tension pneumothorax

Pathophysiology of Shock

• Shock is progressive.

• Events in shock include:

  • Hemodynamic changes

  • Cellular (metabolic) changes

  • Microvascular changes

• Compensatory mechanisms are short-term

Patient Assessment for Shock

• Assess

  • Hemorrhage

  • Level of consciousness

  • Skin

  • Pulse

  • Respiration

  • Blood pressure

  • Confounding factors

• Confounding factors

  • Patient age

  • Medications

  • Pregnancy

  • Pre-existing medical conditions

Shock without Obvious Cause

• The patient is bleeding somewhere, even if you can’t see it

  • Internal hemorrhage

  • Fracture

Penetrating Injuries

• This type of injury occurs when a penetrating object traverses the chest, abdomen, or extremity.

• The object injures organs, tissues, and blood vessels that bleed internally into the surrounding cavities or tissue, or externally.

• As the amount of blood loss increases, signs of shock develop.

Blunt Injuries

• Pathway for blunt injuries is less visible.

• Force is applied to the trunk and extremities.

• Force is transmitted to the thoracic and abdominal organs and bones.

Injuries Commonly Associated with Hemorrhagic Shock

Traumatic Aortic Rupture (Tear)

• Traumatic aortic rupture usually occurs at the junction of the mobile and fixed portions of the aorta just beyond the left subclavian artery.

• Eighty percent to eighty-five percent die prehospital.

  • Of those who survive, 50% die within 48 hours if not treated.

Hemothorax

Abdominal Organ Injury

• Abdominal organ injury results from a blunt or penetrating mechanism.

• Injury to solid organs (liver, spleen, kidney, pancreas) generally results in hemorrhage that varies from mild to life-threatening.

  • It is also associated with leak of enzymes, bile, or urine into abdomen

• Injury to hollow organs (small and large bowel) is usually not a cause of major blood loss; instead, they leak their contents and cause peritonitis.

Fractures

• Major or multiple fractures can lead to significant blood loss.

• Femur or pelvic fractures are the most common cause.

• Don’t underestimate blood loss due to multiple other fractures.

Injuries Commonly Associated
with
Distributive Shock

Neurogenic Shock

• Secondary to spinal cord injury, usually cervical spine (down to T6)

• Loss of sympathetic system vascular tone

• Blood vessels dilate

• Blood return to the heart decreases and cardiac output drops.

• Perfusion and tissue oxygenation is usually maintained.

  • Skin remains warm and dry.

Injuries Common,y Associated with cariogenic shock

Blunt Cardiac Injury

• Blunt mechanism

• Direct injury to heart muscle, which rarely can cause valve rupture

• Broad range of presentations

  • Dysrhythmia

  • New murmur

  • Sudden death

Pericardial Tamponade

• Penetrating mechanism most common

• Blood in pericardial sac

• Increasing amount of blood in the sac compresses the heart, preventing adequate filling; thus, cardiac output decreases

Shock Management - keep them warm

• Four questions guide management:

  • What is the cause of shock in this particular patient?

  • What is the care for this type of shock?

  • What can and should be done between now and the time the patient reaches definitive care?

  • Where is the best place for the patient to get definitive care?

• Reduced cardiac output and impaired tissue oxygenation occur before the blood pressure drops.

• Proper shock management improves the oxygenation of RBCs and improves the delivery of RBCs to the tissues.

  • Airway–what are the needs?

  • Ventilation–does it require assistance?

  • Oxygenation

  • Circulation

• Patient positioning- supine

• Hemorrhage control 

  • Direct pressure will control most external hemorrhage

  • Tourniquet

  • Immobilization of fractures

  • Topical hemostatic agents may be recommended for prolonged transport situations

Distributive (neurogenic)

• Must rule out hemorrhage as the primary cause of shock

• Spine movement restriction (immobilization)

• Transport considerations

  • Transport without delay to appropriate destination

  • Maintain body temperature

    • Patient compartment temperature should be 85 °F (29 °C)

  • Considerations in prolonged transport

    • Ensure airway and optimize ventilatory status.

    • Maintain external hemorrhage control.

    • Prevent body heat loss.

    • Reassess, reassess, reassess.

Minimizing complications

• Assess for shock.

• Assume hemorrhagic shock until proven otherwise.

• Remember: Cardiac output and tissue oxygenation are impaired early.

• Restore and/or maintain airway, ventilation, oxygenation, and circulation.

• Hypothermia creates a cycle of worsening shock and hypothermia.

• Transport without delay.

compensated vs decompensated shock

Compensated and decompensated shock are sequential stages of the same medical emergency. Compensated shock occurs when the body successfully uses its own regulatory mechanisms (like a racing heart rate and narrowed blood vessels) to maintain normal blood pressure. Decompensated shock represents a critical failure of these mechanisms, causing blood pressure to plummet and vital organs to suffer inadequate perfusion