MEDI7302 Study Guide - Final Guide: Thoracentesis, Common Iliac Artery, Nasogastric Intubation
Trauma
Learning
objectives
Demonstrate the concepts and principles of primary and secondary assessment
Establish management priorities
Principles of primary and secondary treatment
Epidemiology Trimodal death distribution
Immediate deaths (50% deaths) - devastating, non-survivable deaths
Early deaths within 1hr (30% deaths) - haematoma, fractures, abdo injuries
(early intervention critical to avoid early death)
Late deaths within 2-3wks post-trauma (20% deaths) - secondary brain
injury, sepsis, further complications
Males - alcohol, young, long bone trauma, MVA
Females - domestic violence
Goals Rapid accurate assessment
Resuscitate and stabilize by priority
Determine needs and capabilities
Arrange for transfer to definitive care
Assure optimum care
Primary
assessment
Purpose - immediately identify and treat life-threatening conditions first; definitive
diagnosis is not immediately important
Primary survey + resuscitation management - DRCAB (medical cardiac arrest) vs
DRSABC (other presentation)
Quick 10sec Identify yourself
Ask patient for identification & what happened ->
patent airway, sufficient airway reserve for speech, clear sensorium
Instruct patient to wiggle toes -> intact spinal cord
Danger Look around for danger (yourself, partner, bystanders,
patient)
Response Determine level of consciousness using AVPU scale
oIs the patient alert?
oIs the patient responding to verbal stimuli
oIs the patient only responding to painful
stimuli
oIs the patient unresponsive?
Airway
maintenance +
C spine
protection
Check for patent airway
oO2 in, CO2 out, cycles of breaths, protected
airway
oObstruction - blood clot, teeth, foreign body,
tongue, vomit, oedema
oAirway manoeuvres, suctioning, airway
adjuncts
Check for protected airway against danger of future
obstruction
oSaliva, secretions, stomach contents into
lungs (stridor, gurgling, grunting)
oGCS <9 is unprotected airway (unconscious,
coma)
oETT for protection (prevent aspiration by
blocking esophagus)
Management
oC spine immobilisation (manual stabilization
-> hard collar)
oRemove foreign bodies - suctioning of blood
or foreign material
oSimple airway manoeuvres (jaw thrust & chin
lift)
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oBasic and advanced airways adjuncts - OPA
oropharyngeal, NPA nasopharyngeal, LMA laryngeal mask airway
(opening into trachea & block off esophagus), ETT endotracheal
intubation via laryngoscope
oIf ETT fails, intervene with cricothyroidectomy
Surgical airway if significant bleeding or obstruction
Breathing +
ventilation
Assessment
oCheck for breathing and adequate ventilation
oRespiratory rate, rhythm and SpO2
oExposure and inspection - external trauma
signs, asymmetrical chest movements
oPalpation - unsuspected injuries (crepitus,
surgical emphysema)
oPercussion
oAuscultation - listen for bilateral air entry,
assess for added sounds
oTrachea - midline or deviation?
oAny obvious chest wall injuries?
Decreased central respiratory drive (head injury,
intoxication, fatal shock) or chest injury (hemothorax, pneumothorax, rib
fracture) can threaten adequate ventilation
Management
oAdequate analgesia
oO2 titrated to SaO2 via nasal cannula ->
Hudson mask or non-rebreather mask -> high flow nasal cannula ->
non-invasive ventilation -> intubation and ventilation
oNeedle thoracotomy, finger thoracotomy or IC
catheter insertion may be required
Circulation +
hemorrhage
control
Assessment
oHR, BP, capillary refill and peripheral
perfusion (warm or cold clammy)
oConscious state (brain perfusion)
oLook for bleeding (chest, abdomen,
retroperitoneum, pelvis, long and externally)
oLook for signs of shock (tachypnoea, dusky
colour, diaphoresis, altered mental state, poor cap refill)
Important equations
oBP = SVR x CO
oCO = HR x SV
oSV = EDV - ESV
oEjection fraction = SV / EDV
oMAP = DBP + 1/3(SBP - DBP)
Shock pathophysiology
oCycle of bleeding -> acidosis -> hypothermia
-> coagulopathy …
oHypovolemic
Hemorrhagic shock is most common
in trauma
Burns, GIT loss
Blood loss -> SNS vasoconstriction to
maintain BP + speed up HR -> tachycardia, then reduced pulse
pressure, then hypotension -> poor organ perfusion from low
blood volume (peripheries -> brain)
Inadequate perfusion -> cell hypoxia
-> energy deficit -> lactic acid and pH fall via anaerobic
metabolism -> metabolic acidosis (vasoconstriction &
peripheral pooling of blood) -> cell membrane dysfunction,
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electrolyte disturbance, failure of Na/K pump (Na and water in
+ K out) -> intracellular lysosome release -> toxic substances
enter circulation -> damage capillary endothelium ->
destruction, dysfunction, death
oCardiogenic
LV failure (75%), myocarditis,
arrhythmia, congenital or valvular lesions
Poor myocardial contractility ->
reduced cardiac output -> poor organ perfusion + high venous
pressure from fluid retention -> SNS vasoconstriction to
maintain BP
oDistributive
Sepsis, anaphylaxis, neurogenic
(spinal or epidural anaesthesia)
Complete vessel dilation and capillary
leak -> hypovolemia, hypotension, poor organ perfusion
Give fluid therapy
oObstructive
Obstruction to heart function - lung
emboli, cardiac tamponade, pneumothorax
Poor organ perfusion -> SNS
vasoconstriction -> venous congestion from pressure backlog
Management
o2 large bore (16g) IV cannulas into the
antecubital fossa (or intraosseous access)
oBloods
"Trauma bloods", crossmatch for
group & hold
VBG for lactate, initial Hb
Other tests include FBC, UaE,
creatinine, glucose, coagulation profile and lipase (and b-hcg
for woman)
oHemorrhage control
Direct pressure (bandage, tourniquet,
pelvic binder)
Bleeding sites - pelvis fracture (2L
blood), femoral fracture (1L blood), lung, extremities
Other measures are considered major
hemorrhage requiring damage control surgery (ligate, shunt,
repair)
oCommence warm IV fluids (Hartman or
normal saline) - 20mL/kg
oHemorrhagic shock
1-2L warm IV crystalloid
If required, massive transfusion
protocol (blood + clotting factors + platelets)
oMonitor ECG, O2 sats, urinary output
oPlace pregnant women in left lateral
decubitus position
Disability
(neurological
status)
Assessment
oGCS score & pupil size and response
(intracranial injury) - GCS < 9 requires ETT; important indicator is
deteriorating GCS
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Document Summary
Demonstrate the concepts and principles of primary and secondary assessment. Immediate deaths (50% deaths) - devastating, non-survivable deaths. Early deaths within 1hr (30% deaths) - haematoma, fractures, abdo injuries (early intervention critical to avoid early death) Late deaths within 2-3wks post-trauma (20% deaths) - secondary brain injury, sepsis, further complications. Males - alcohol, young, long bone trauma, mva. Purpose - immediately identify and treat life-threatening conditions first; definitive diagnosis is not immediately important. Primary survey + resuscitation management - drcab (medical cardiac arrest) vs. Ask patient for identification & what happened -> C spine protection patent airway, sufficient airway reserve for speech, clear sensorium. Instruct patient to wiggle toes -> intact spinal cord. Look around for danger (yourself, partner, bystanders, patient) o o o stimuli o o airway o. O2 in, co2 out, cycles of breaths, protected. Obstruction - blood clot, teeth, foreign body, tongue, vomit, oedema o adjuncts. Check for protected airway against danger of future obstruction o.
