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Initial Management

in

Trauma Patient

ผศ.นพ.ก ำธน จนทรแจม

หนวยศลยศำสตรอบตเหตและวกฤต ภำควชำศลยศำสตร

คณะแพทยศำสตร มหำวทยำลยเชยงใหม

OVERVIEWS

• Initial assessment and resuscitation for trauma

patient

• Advanced Trauma Life Support (ATLS) 10th

Edition

Advanced Trauma Life Support (ATLS)

• หลกสตรมำตรฐำนส ำหรบ

ผปฏบตงำนดแลผบำดเจบ

กอนทหองฉกเฉนในชวงแรก

• เพอลดอตรำกำรเสยชวตจำก

กำรบำดเจบ

• Edition 10 (update 2017)

Trimodal Death Distribution

Preparations

• Universal precaution

• Cap

• Mask / Shield / Goggles

• Gown

• Gloves

• Shoes / Shoes cover

กำรคดแยกผบำดเจบ (Triage)

• Multiple Casualties จ ำนวน

ผบำดเจบไมมำก สำมำรถรกษำ

ไดทกคนดวยทรพยำกรทม รกษำ

ผทมอนตรำยตอชวตมำกทสด

กอน

• Mass Casualties ทรพยำกร

จ ำกด เมอเทยบกบจ ำนวน

ผบำดเจบ รกษำผทมโอกำสรอด

ชวตกอน

Concepts of ATLS

Adjunct to primary survey

Consider need for transfer

Secondary survey (head to toe evaluation and history)

Adjunct to secondary survey

Primary survey and simultaneous resuscitation

Continue monitoring & Re-evaluation

Definitive care VS Transfer

Primary Survey

• A : Airway maintenance with restriction C-spine motion

• B : Breathing and Ventilation

• C : Circulation and Hemorrhagic control

• D : Disability (Assessment of neurological status)

• E : Exposure and Environmental control

Airway & Restriction C-spine motion

• First priority !!!

• Quick assessment : ถำมผปวย

• ตรวจรำงกำย : Signs of airway obstruction (stridor, เลอด

secretion, FB เปนตน

• Protection of C-spine ตลอดเวลำทประเมนและดแลทำงเดน

หำยใจ

• Severe Maxillo-facial injury

Potential Airway Compromise

• Inhalation injury (Facial burn)

Potential Airway Compromise

• Neck injury (blunt & penetrating)

Potential Airway Compromise

Exclusion of C-spine injury

NEXUS

criteria

• MILS, remove collar

• Palpation for

tenderness

• Rotation

• Neck flexion

Restriction of C-spine

• สวม Philadelphia's collar และ

ใหผปวยนอนบน Long spinal

board

• ตด Head immobilizer และม

Straps รด

• Further investigation

Airway Maintenance Techniques

Basic or Temporary airway

maintenance

• Chin lift / Jaw thrust

• Suction and removal of FB

• Oropharyngeal /

Nasopharyngeal airway

• Restriction of C-spine with MILS

!!

Basic Airway Maintenance

Chin Lift

• With Manual in line stabilization (MILS)

Jaw thrust

Basic Airway Maintenance

• Oropharyngeal Airway

Basic Airway Maintenance

• Nasopharyngeal

Airway

Airway Maintenance

Advance or Definitive airway maintenance

• Endotracheal Intubation : Orotracheal / Nasotracheal

Intubation

• Surgical Airway : Surgical Cricothyroidotomy /

Tracheostomy

Indications for Definitive Airway

• Apnea

• Airway compromise

• Protection from

aspiration

• Potential or Impending

airway compromise

• GCS < 9 (severe head

injury)

• Obtunded due to cerebral hypoperfusion

• Failed face mask

ventilation

Definitive Airway

• สวนมำกจะท ำเปน Orotracheal Intubation with Manual-in-

line Stabilization (MILS)

Definitive Airway

• Surgical Cricothyroidotomy

• ไมสำมำรถใสทอชวยหำยใจได

• ในผปวยทม Difficult airway เชน

severe maxillofacial injury

Surgical Cricothyroidotomy

Adjuncts Airway Maintenance

• Laryngeal Mask Airway (LMA)

• Laryngeal Tube Airway (LTA)

• Multi-lumen Esophageal tube

• Gum Elastic Bougie (GEB)

• Needle cricothyroidotomy with jet insufflation

• Video laryngoscopes

Laryngeal Mask Airway (LMA)

i-gel�supraglottic airway

Laryngeal Tube Airway (LTA)

Multi-lumen Esophageal Tube

Multilumen Esophageal Tube

Gum Elastic Bogie (GEB)

• แนะน ำใหใช GEB เมอใส orotracheal intubation ไมส ำเรจใน first

attempt หรอมองเหน vocal cords ไดยำก

• Needle Cricothyroidotomy with Jet Insufflation

Needle Cricothyroidotomy

Video Laryngoscope

Breathing & Ventilation

Evaluation by Physical Examinations

• ด (Look) : chest movement, แผล, neck vein

• คล ำ (Palpation) : trachea

• เคำะ (Percussion)

• ฟง (Auscultation)

Breathing & Ventilation

• Oxygen supplement

• Mask with reservoir bag at least 11 L/min

• Nasal cannula

• ET-tube with Mechanical ventilator

• ชวยหำยใจ (assist ventilation) กอน ระหวำง และ หลงกำรท ำ

definitive airway ในผปวยทม respiratory failure

Breathing & Ventilation

• ตรวจหำภำวะทเปน Immediate life-threatening injury ไดแก

Tension pneumothorax

Massive hemothorax

Open pneumothorax

Flail chest

Tension Pneumothorax

• Most treatable

• Dyspnea / abnormal chest

expansion

• Tracheal deviation, decrease

BS

• Hyperresonance on

percussion

• Hypotension, neck vein

distension

Tension Pneumothorax

Management

• Needle thoracocentesis

• 2nd ICS Midclavicular line

(ATLS ed9)

• ICD : no. 28-32, 5th ICS just anterior to midaxillary lineImmediately after needle

Management (ed 10)

• Needle thoracocentesis at 4-5th ICS slightly anterior to Midaxillary line : success rate มากกวา (แนะน าใหใชในAdult)

• Children : 2nd ICS MCL

• Finger decompression ถาใชเขมแลวไมส าเรจ

Massive Hemothorax

• Massive bleeding in pleural cavity / Shock

• Immediately drain > 1,500 cc from ICD

• Diagnosis (Clinical)

Dullness on percussion

Decrease breath sound

S/S of Shock

Massive Hemothorax

• Fluid resuscitation / blood

transfusions

• ใส ICD ประเมนวำมเลอดออกปรมำณ

เทำไหร

• ER thoracotomy / Emergency

thoracotomy

• Autotransfusion

Open pneumothorax

• Sucking chest wound

• Diagnosis : ทลมผำนเขำ-

ออก จำกแผลททรวงอก

• One-way valve : develop

tension pneumothorax

• Air pass through defect :

hypoventilation

Open pneumothorax

Management

• 3-sided sterile occlusive

dressing

• ICD หำงจำกแผล

• Temporary closure of

defect

Flail Chest

• เกดเมอม Segmental ribs fracture

ตดกน 2 ซหรอมำกกวำ

• Paradoxical chest movement

• เหนไดชดถำอยทำงดำน Anterior or

lateral part of chest wall

• อำกำรอน ๆ : Dyspnea,

subcutaneous emphysema,

decrease breath sound

Paradoxical chest

movement

Flail Chest

สำเหตของ Respiratory failure ใน flail chest

• Pain

• Hemothorax / pneumothorax

• Lung contusion

• Loss of lung mechanics (paradoxical

chest movement)

Flail Chest

Management

• ให Oxygen supplement

• ใส ICD ถำพบวำม Pneumothorax / Hemothorax

• ระวงไมให crystalloid fluid overload

• Control pain

• พจำรณำ intubation with mechanical ventilation (PaO2 < 60

mmHg or O2 sat < 90%)

Circulation & Hemorrhagic

control

• Identify patient's circulation : Shock ?

• หำสำเหตของ shock

• ให Fluid resuscitation

• Control hemorrhage แกไขสำเหตของ shock

Symptoms/Signs of Shock

• Blood pressure, Pulse rate, Respiratory rate

• Consciousness

• Peripheral pulse and perfusion : capillary refill,

temperature, sweating

• Urine output

• Base deficit

Causes of Shock

• Hypovolemic shock (most common) :

• External bleeding, chest, abdomen, pelvis and long

bone fracture

• Cardiogenic shock : cardiac tamponade, tension

pneumothorax, blunt myocardial injury, MI

• Neurogenic shock

• Septic shock

Management of Shock

• Control of hemorrhage

• แกไขสำเหตอน ๆ ของ shock

• Resuscitation

Control External bleeding

• Manual compression

• Splint and traction

• Elastic bandage

• Full thickness suture

• Tourniquet

• Others : Nasal packing

Direct pressure

&

Bandaging

Tourniquet

Pelvic Exam

Pelvic Binder for Pelvic Fracture

Pelvic Sheet Wrapping

Traction Splint for Femur Fracture

Cardiac tamponade

FAST (subxiphoid)

กำรรกษำ

• Pericardiocentesis

• Median sternotomy / Thoracotomy

Neurogenic shock

• Loss sympathetic tone เกดจำก spinal cord injury ระดบสง

กวำ T6

• Hypotension, no tachycardia, warmed skin

• กำรแกไขเบองตน :ใหสำรน ำใหเพยงพอ (Euvolumia), พจำรณำ

ให vasopressor

• Support ventilation ในรำยทมกำรบำดเจบสงกวำ C6 level

Resuscitation

Venous Access

• Large size angiocatheter (peripheral vein) - 18G

• Vital sign stable : 1 extermity

• Vital sign unstable : 2 extermities

• Upper > Lower extremity

Resuscitation

• Central venous access

Cut down (Saphenous vein)

Femoral / Subclavian vein

• Intraosseous cannulation :

ใชไดทกอำย / ใชช วครำวหลงจำกเปด peripheral line ไมได

• Obtain blood for LAB/Crossmatching

Intraosseous Cannulation

Femoral vein catheterization

Types of Fluid resuscitation

• Isotonic crystalloid solution (Warmed LRS, NSS, Acetar)

• Initial : 1 L bolus or 20 cc/kg (ถำ นน. > 40 kg) , without

aggressive resuscitation, frequent re-evaluation

• Precaution : Penetrating injury “permissive

hypotension” กอนจะท ำกำรผำตดในรำยท shock

Evaluation of Response

Transient / No Response

• Early blood and blood products

transfusion (hemostatic

resuscitation)

• PRC, FFP, platelets

• Exsanguination : PRC type O,

FFP type AB มไวท ER

• MTP (Massive transfusion

protocol)

MTP

• Protocol เพอทจะไดเลอดอยำง

รวดเรว - แตกตำงกนในแตละ

โรงพยำบำล

• แนะน ำ Low ratio (FFP:PRC

ระหวำง 1:1 ถง 1:2)

• รพ.มหำรำช MTP 1 box

ประกอบดวย PRC:FFP:platelet

อยำงละ 4 units

Transient / No Response

• Correct coagulopathy อยำงตรง

จด

• Thromboelastogram (TEG) or

Rotational

Thromboelastometry (ROTEM)

• Transamine 1 g IV in 10 min

then 8 hours (มประโยชนถำให

ภำยในเวลำ 3 ชม.)

Thromboelastogram (TEG)

Coagulation factors Fibrinogen Platelets

Disability (Neurological assessment)

• Brief baseline neurological assessment

Level of consciousness (new GCS)

Pupillary size and reaction

• ประเมนซ ำบอย ๆ

• Limbs movement

Exposure and Environment

control

• Completely undress in severe injured patient

• Logrolling : Exam back and Per-rectal examination

• Keep warm : ปองกนภำวะ hypothermia

Warm blanket, warm IV, external warming device

Adjuncts to Primary survey

Monitoring

• Vital signs

• Pulse oximetry, RR, ABG

• EKG

• End tidal CO2 : monitor adequate

ventilation, confirm ET tube in

trachea, ประมำณคำ cardiac output

และ predict ROSC ในกรณท ำ CPR

Adjuncts to Primary survey

Radiography

• CXR

• Pelvic X-ray

• FAST, eFAST

• should be performed in resuscitation area

CXR Interpretation

• D : Detail

• R : Rotation, Inspiration, Picture,

Exposure

• S : Soft tissue & Bone

• A : Airway

• B : Breathing

• C : Circulation

• D : Diaphragm

• E : Extra (tube & line)

FAST (Focused Assessment

Sonography in Trauma)

e-FAST (extended FAST)

Pneumothorax Hemothorax

Adjuncts to Primary survey

• Gastric tube : decompress

stomach (avoid NG tube in

patient with base skull

fracture)

• Urinary catheter :

precaution in BPH,

stricture

Bleeding per meatus Scrotal & Perineal ecchymosis

• contraindication for Foley's catheter

• Palpation of the prostate gland is not a reliable sign of

urethral injury

Suspected Urethral Injury

Retrograde Urethrogram

Consider need for Transfer

• ไมควรท ำ diagnostic investigation ทไมจ ำเปน ซงจะท ำให

delay transfer

• ท ำเฉพำะทชวยในเร อง resuscitate เพอใหผปวยมอำกำรคงท และ

ปลอดภยทจะ transfer ได

• Communication

Secondary Survey

• Perform after

Primary survey is completed

Resuscitation has been performed

Re-evaluation vital signs

• Complete history taking and Physical Examination

Secondary Survey

Essential Historical Element "AMPLE"

• A : Allergies

• M : Medications

• P : Past illness, Previous operation, Pregnancy

• L : Last meal

• E : Events & Environment related to injury

Secondary Survey

• Complete Physical Examination

• "Head to Toe"

• Prevent "Missed" injury

• รวมทงกำรท ำ PV ใน female patient with pelvic fracture

Adjuncts to Secondary survey

• กำรตรวจวนจฉยเพมเตม ส ำหรบกำรบำดเจบทตรวจพบทงหมด

X-rays for spine and extremities

CT scan

Contrast studies

Other diagnostic intervention

• ควรท ำเมอผปวยมสญญำณชพคงทเทำนน

Adjuncts to Secondary survey

C-spine clearance

• MDCT

• Plain X-ray ถำไมม MDCT

• Normal X-ray (adequate &

good interpreter) : remove

collar ท ำ flexion-extension

film

• Inadequate X-ray : MDCT

Adjuncts to Secondary survey

TL-spine clearance

• GCS 15, no pain or

tenderness, no neuro deficit

• ถำมไมครบ : MDCT

• ถำไมม MDCT : plain X-ray

with good quality &

interpreter

• Long spinal board : not more

than 2 hours

DEFINITIVE CARE

VS

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