TraumaAirwayMGMT - Initial Assessment of the Trauma Patient...

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Unformatted text preview: Initial Assessment of the Trauma Patient Trauma Sharla Owens, M.D. July 10th, 2006 Never Let Don’t Panic Don’t Don’t Panic Them See You Sweat.. ATLS Guidelines ATLS Systematic approach necessary to rapidly Systematic identify injuries and stabilize the patient identify This approach is divided into: 1. Primary Survey 2. Resuscitative Phase 3. Secondary Survey 4. Definitive Care Phase ABCDE ABCDE Airway Management in the Trauma Patient Trauma Objectives of Airway Management & Ventilation Ventilation Primary Objective: – Provide unobstructed passage for air Provide movement movement – Ensure optimal ventilation – Ensure optimal respiration Objectives of Airway Management & Ventilation Ventilation Why is this so important in the trauma Why patient? patient? – Prevention of Secondary Injury Shock & Anaerobic Metabolism Spinal Cord Injury Brain Injury Airway Airway Patency is primary Obstruction in trauma patients – Tongue – Swelling – Foreign Body – Blood and secretions Airway Airway Evaluation begins by asking the patient a Evaluation question such as 'How are you?‘ question A response given in a normal voice indicates that the airway is not in immediate jeopardy; a breathless, hoarse response or no response at all indicates that the airway may be compromised. Airway Airway Mechanical removal of debris, chin lift Mechanical and/or jaw thrust maneuver, are usefull in clearing the airway in less injured patients clearing If there is any question of an adequate If airway, severe head injury, profound shock, severe facial trauma, voice changes, then definitive airway control is necessary necessary Airway & Ventilation Methods Airway Supplemental Oxygen – increased FiO2 increases available oxygen – objective is to maximize hemoglobin objective saturation saturation Airway & Ventilation Methods Airway Airway Maneuvers – Chin lift – Jaw thrust (Neck extension is contraindicated) Airway Devices Airway – Oropharyngeal airway – Nasopharyngeal Nasopharyngeal airway airway – BVM Assessment & Recognition of Airway & Ventilatory Compromise Ventilatory Visual Assessment – Position tripod orthopnea – Rise & Fall of chest Paradoxical motion – Audible gasping, Audible stridor, or wheezes stridor, – Obvious pulm edema Obvious Visual Assessment – – – – – – – Skin color Flaring of nares Pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or Inadequate depth of ventilations depth Airway & Ventilation Methods Airway Gastric Distention – Common when ventilating without intubation – pressure on diaphragm – resistance to BVM ventilation – avoid by increasing time of BVM ventilation Airway & Ventilation Methods Airway Orotracheal Intubation- preferred in Orotracheal almost all situations almost – Indications present or impending respiratory failure apnea unable to protect own airway (GCS <8) – Advantages secures airway route for a few medications optimizes ventilation and oxygenation Airway & Ventilation Methods Airway Nasotracheal Intubation- rarely if ever Nasotracheal used in the initial management of the injured patient. injured Many drawbacks Goal of safe endotracheal intubation with Goal cervical spine precautions can be better accomplished with orotracheal intubation accomplished Airway & Ventilation Methods Airway Surgical Cricothyrotomy – Indications absolute need for a definitive airway AND – unable to perform ETT due for structural or anatomic unable reasons, AND reasons, – risk of not intubating is > than surgical airway risk OR absolute need for a definitive airway AND – unable to clear an upper airway obstruction, AND – multiple unsuccessful attempts at ETT, AND – other methods of ventilation do not allow for effective other ventilation and respiration ventilation Airway & Ventilation Methods: ALS Airway Surgical Cricothyrotomy – Contraindications (relative) Age < 8 years (some say 10) evidence of fx larynx or cricoid cartilage evidence of tracheal transection Airway & Ventilation Methods Airway Needle Cricothyrotomy & Transtracheal Jet Needle Ventilation Ventilation – Indications Same as surgical cricothyrotomy along with Contraindication for surgical cricothyrotomy – Contraindications caution with tracheal transection Airway & Ventilation Methods: Jet Ventilation Jet – Usually requires highpressure equipment – Ventilate 1 sec then Ventilate allow 3-5 sec pause allow – Hypercarbia likely – Temporary: 20-30 Temporary: mins mins – High risk for High barotrauma barotrauma Airway & Ventilation Methods Airway Pharmacologic Assisted Intubation (“RSI”) – Sedation Used for – induction – anxious or agitated patient Contraindications – hypersensitivity – hypotension (e.g. hypovolemia 2° to trauma) Airway & Ventilation Methods Airway Pharmacologic Assisted Intubation (“RSI”) – Neuromuscular Blockade Neuromuscular Induces temporary skeletal muscle paralysis Induces Indications – When Intubation is required in a patient who is awake, has a gag reflex, or is agitated or combative Airway & Ventilation Methods Airway Pharmacologic Assisted Intubation (“RSI”) – Neuromuscular Blockade Neuromuscular Contraindications Contraindications – Most are specific to the medication – inability to ventilate patient once paralysis is induced Advantages – reduces risk of laryngospasm Airway & Ventilation Methods Airway Pharmacologic Assisted Intubation (“RSI”) – Disadvantages & Potential Complications Does not provide sedation or amnesia Provider unable to intubate or ventilate after NMB Aspiration during procedure Difficult to detect motor seizure activity Side effects and adverse effects of specific meds Tension Pneumothorax Tension Recognizing Life Threatening Emergenies Emergenies Aka, “When to pee in your Aka, pants in the trauma bay” pants Tension Pneumothorax Tension Signs and Symptoms severe respiratory distress or absent lung sounds (unilateral usually) or resistance to manual ventilation resistance Cardiovascular collapse (shock) asymmetric chest expansion anxiety, restlessness or cyanosis (late) JVD or tracheal deviation (late) Great Vessel Injury Great Aortic Transection Aortic Signs: - widened mediastinum, 1st rib fx, apical capping, left hemothorax, tracheal deviation to right left - widening from bridging veins and arteries, not widening aorta itself aorta - need aortic evaluation in pts with significant need mechanism (deceleration injuries), usually tears at ligamentum at - 90% of patients die at the scene Cardiac Tamponade Cardiac Cardiac Tamponade Cardiac Beck’s triad: - hypotenstion, jugular venous distention, hypotenstion, and muffled heart sounds and - causes decreased diastolic ventricular causes filling and resultant hypotension filling - echocardiogram shows impaired diastolic echocardiogram filling of right atrium initially (1st sign) filling Traumatic Brain Injury Traumatic Epidural Hematoma SA Hemorrhage TBI: TBI: High index of suscpicion in any patient High with history of or identifiable evidence of altered level of consciousness altered Best determined by GCS (a decrease of Best even 1-2 points is indicative of significant change in neurological status) change Pupillary function Lateralizing signs Solid Organ Injury Solid Splenic Laceration Liver Laceration Solid Organ Injury Solid 25% of all trauma victims require an 25% abdominal exploration abdominal Blunt trauma caused by MVCs, MCCs, Blunt falls, assaults, and auto vs. pedestrians remains the most frequent mechanism of injury injury High index of suspicion in those patients High with c/o abdominal pain, and/or objective findings on exam (seatbelt sign) findings Hemorrhage Hemorrhage Pelvic fracture Pelvic Trauma Pelvic Pelvic fx are the prototype of severe Pelvic trauma, with an usually high incidence of associated injuries associated Awake pts c/o excessive pain and may Awake have evidence of abnormal positioning of lower extremities, or unstable pelvis on exam exam Can be a major source of blood loss that is Can either arterial, venous, or osseous in origin either ...
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