Trauma Overview, Primary survey and Scene management

What is the AAP’s role in trauma?

• Rapid Primary Survey + Essential Management

• Supporting senior clinician

  • Equipment

  • Communication

  • Anticipation

• Maintain momentum

• Scene management

• Management of wounds and injuries

What should you remember about major blood loss?

• ‘Blood on the floor + four more’ = if not obvious external bleeding, need to consider internal

• ‘Four more’ = Major areas of internal bleeding potential

  • Chest cavity

  • Pelvis

  • Abdominal cavity

  • Long bones

• Young, healthy patients may initially appear well

  • E.g. HR 100 and RR 24 look normal - but for fit healthy person could be double their normal rate!

How does the body physiologically compensate for blood loss/Haemorrhagic/Hypovolaemic stroke?

Signs of compensation for blood loss to maintain BP:

• First sign is increased respiratory rate first (take RR)

• Increased heart rate (take pulse, might be weak thready pulse)

• Vasoconstriction (cold peripheries, pale)

What are some reasons we miss seriously injured patients?

• Arriving early before deterioration occurs

• Lack of experience dealing with major trauma

• Underestimating mechanisms of injury

• Falsely reassured by compensation

What are some high risk patient groups in trauma and why are they high risk?

• Elderly (‘silver trauma’)

  • Often under triaged (mechanism does not present very dramatically, elderly tend to underplay symptoms)

  • Frailty (lower bone density, less muscle mass)

  • Co morbidities (COPD, heart failure etc.)

  • On medications that prevent compensation (blood thinners, BP medications, beta blockers)

  • Difficult to assess (existing dementia/delirium)

• Children (risk taking behaviours, decompensating quickly, not fully physically developed, difficulty communicating)

• Intoxicated adults (risk taking behaviours, difficulty communicating, intoxication masking neuro injuries, slower clotting)

• Pregnant patients (2 patients, increased blood volume)

• Morbidly obese people (systems already under strain, difficult to identify internal bleeding/pain/injuries covered by adipose tissue, more mass = more energy)

• Anti-coagulant medications (blood thinners)

What should your first 10 minutes of trauma assessment be?

• Rapid assessment of life threatening injuries (Primary survey order)

• Simultaneous assessment and management and you meet problems in primary survey order

• Assume the worst → treat or exclude (e.g. called to assault at pub, need to assume been stabbed so stab check to treat or exclude)

• Minimise on-scene times:

  • Penetrating trauma needs to be conveyed ASAP

  • Blunt trauma <20 minutes (usually more you have to do, e.g. extricating, immobilising)

What are the elements of a Primary Survey modified for trauma, and what should you specifically consider for trauma?

DR <C> AcBCDE

• Danger (Attacker? Traffic? Unstable objects? Height? Rail?)

• Response (AVPU)

• Catastrophic haemorrhage (address immediately)

• Airway (teeth, blood, vomit, tissue)

  • cervical spine control (manage airway with awareness of potential c-spine injury [e.g. keeping flat and still])

• Breathing (consider bruising, broken ribs, equal air entry, equal chest rise and fall)

• Circulation (pulse checks, feeling cap refill, cold peripheries? Pale?, check for any non-catastrophic haem around body, especially internal)

• Disability (Head injuries [AVPU, GCS, Pupils], spinal injuries [normal sensation and movement in all limbs?])

• Evaluate/expose (take off all clothes to exclude all worst case scenarios [internal bleeding, penetrating trauma], areas to check are groin, under arms, buttocks, back) → then cover back up and keep warm

Treat as you go. Reassess. Any primary survey failures = transport NOW!

When would you do a secondary survey for trauma?

On the way to hospital only, or if patient is DEFINITELY stable

What treatment do we give to any major trauma patient?

• High flow 15lpm oxygen via non-rebreather mask once airway is clear

• Consider any patient that has a serious head injury or loss of consciousness to have a spinal injury (until proven otherwise)

What are some elements you can control to ensure good scene management?

• Vehicle placement

• Maintain an overview of the scene and keep up momentum

  • Your senior clinician may be occupied on treatments

  • You should encourage conveyance where treatment can be done in the ambulance

• Involve everyone (match with skill level)

  • Who is holding the head? Can you free up a senior clinician by doing this yourself? Can you ask a police officer or fire fighter to do this?

• Anticipate, prepare, plan

  • Think about end result (getting to hospital quickly)

    • Equipment out

    • Trolley out

    • Ambulance turned around

    • Exit route planned

    • Communicate with family/mps etc.

• Commmunicate

• Do you need further help? (APPCC, HEMS, LFB, HART, MPS, another crew?)

What are key takeaways for trauma management?

• Good airway management saves lives

• Hypoxia and hypertension indicate significant bleeding - treat early and well (High flow, airway management, identify bleeding and stop/slow, escalate to senior clinicians)

• Expose patient fully (and keep warm afterwards)

• Minimal movement (the 1st clot is the strongest)

• Pre-empt crew mate, anticipate and prepare

• Think early: do you need help?

• Get patient to right place, right time, first time