Approach to trauma resident rounds july 17 th 2003 rob hall pgy4
Download
1 / 29

APPROACH TO TRAUMA Resident Rounds July 17th, 2003 Rob Hall PGY4 - PowerPoint PPT Presentation


  • 121 Views
  • Uploaded on

APPROACH TO TRAUMA Resident Rounds July 17 th , 2003 Rob Hall PGY4. What is your approach?. Ouch …… . Key Points . Systematic approach to trauma is a must Triage tools Prehospital trauma management How to “ manage the trauma room ” Priorities in the multitrauma patient

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'APPROACH TO TRAUMA Resident Rounds July 17th, 2003 Rob Hall PGY4' - kapono


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Approach to trauma resident rounds july 17 th 2003 rob hall pgy4 l.jpg

APPROACH TO TRAUMAResident Rounds July 17th, 2003Rob Hall PGY4

What is your approach?


Slide2 l.jpg
Ouch…….


Key points l.jpg
Key Points

  • Systematic approach to trauma is a must

  • Triage tools

  • Prehospital trauma management

  • How to “manage the trauma room”

  • Priorities in the multitrauma patient

  • PEARLs of the primary survey

  • PEARLs of adjuncts and investigations


Case presentation you know you re having a bad day when l.jpg
Case Presentation: you know you’re having a bad day when………….

  • 50ish yo female

  • Gets up in am, lights a smoke

  • Gas leak overnight ->EXPLOSION

  • She is blown out the second story patio door and is found lying on a driveway ON THE OTHER SIDE OF THE STREET

  • Husband is dead inside burning building


Who needs transport to a trauma center l.jpg
Who needs transport to a trauma center?

  • Case: does this patient need a trauma center? Why?

  • What criteria do you use?

    • Triage decision scheme from ACS (see ATLS)

    • Revised Trauma Score (RTS)

    • Injury Severity Score (ISS)


How to prepare for a trauma patient l.jpg
How to prepare for a trauma patient?

  • How would you prepare for this case?

  • Personel

    • RN, RT, DI, Notify trauma surgeon if nasty

  • Equipment

    • Think of what you will need in primary survey

    • Anticipate what you will use

      • GSW to abdomen, BP 50 ->get some blood hanging in the level I infuser

      • Draw RSI drugs in advance

      • Make sure you have all of the equipment you will need if you are working in a smaller center


The paramedic report l.jpg
The Paramedic Report

  • What do you want to hear in the report?

  • Mechanism of injury

    • Key point of history

    • Pay close attension

    • Predicts certain injuries

  • Suspected injuries

  • Stability of vital signs

  • Treatments they have given

  • PMHx/med/all if known and relevant


Example of importance of moi side impact versus front impact l.jpg

Driver side impact

Cspine

Left h/pthrx

Splenic lac

Lateral compression pelvic fracture

Left femur fracture

Front end collision

Cspine

Mediastinal injury

Any intraadbo injury

Anterior compression pelvic fracture

Posterior hip dislocations

Bilateral femur/tib/fib fractures

Calcaneal fractures, pilon fractures

Example of importance of MOI:Side impact VERSUS Front impact


Prehospital trauma management l.jpg
Prehospital Trauma Management

  • Case: what do you want the medics to do?

  • BLS

    • C spine, spine board, basic airway maneuvers, oxygen and BVM, control of external hemorrhage, scoop and run

  • ALS

    • Some controversy re advanced airway mx

    • Iv fluids: no evidence for prehospital fluids

  • BLS care and RAPID TRANSPORT are the most important


Case the trauma arrives l.jpg

Case: the trauma arrives

MOI: 70% burn + trauma

Unable to intubate X 2; BVM

Agonal resps, BP 60 palp, HR 140

No sat obtainable, No iv access

? Head injury: GCS 3, external signs of head trauma

What is your approach?


Atls approach good but not perfect l.jpg

PRIMARY SURVEY

Airway

Breathing

Circulation

Disability

Exposure

Full Vitals

ADJUNCTS

CXR, PXR, Cspine

NG, foley, ECG

Monitors, trauma panel

DPL, FAST if needed

SECONDARY

AMPLE hx

Full head-to-toe

ADJUNCTS

CT, FAST, DPL

Extremity Xrays

Angiography

Endoscopy

Contrast studies

ATLS approach: good but not perfect



Breathing l.jpg
Breathing ……




Pearls of the abcs l.jpg
PEARLS of the ABCs

  • Consider yourself stuck until you have dealt with an issue

  • Frequent reassessment

  • Start from A whenever there is a problem

  • Secondary survey is truly secondary


Pearls of abcs l.jpg
PEARLS of ABCs

  • 25 yo male

  • Motorbike into pole at 80 km/hr

  • Helmet damaged

  • Intubated by EMS

  • HR 75 BP 60 palp Sats 97% GCS 6

  • What is the differential dx of shock in a trauma patient?


Ddx of shock in the trauma patient l.jpg
Ddx of shock in the trauma patient

Hypovolemic/Hemorrhagic shock

  • Chest (note: not likely aortic injury)

  • Belly

  • Pelvis

  • Femurs

  • External hemorrhage (esp scalp)

  • Neurogenic

  • Brainstem herniation (preterminal)

  • Other: example -> MI then crashed car


  • Pearls of managing shock l.jpg

    How much initial fluid?

    Which fluid?

    When to give blood?

    When to give blood products?

    What tests will help you?

    2-3L (20-60ml/kg)

    Crystalloid

    After 2-3L or 20-60ml/kg crystalloid

    > 4 units prbc.s: order 4 units FFP and 10 units platelets

    EARLY CXR/PXR and FAST will help you identify the etiology of shock

    PEARLS of managing shock


    Pearls of the abcs20 l.jpg
    PEARLS of the ABCs

    • 50 yo male

    • Small plane crash

    • Transported by STARS

    • Intubated by STARS

    • HR 120 BP 100 Sats 75% on 100% oxygen

    • What is the differential dx of hypoxemia in a trauma patient?


    Differential dx of hypoxemia in trauma l.jpg
    Differential Dx of Hypoxemia in trauma

    • Airway obstruction

    • Pneumothorax

    • Hemothorax

    • Pulmonary contusion

    • Trachobronchial transection

    • Aspiration

    • Atelectasis

    • ARDS

    • Pulmonary hemorrhage

    • Fat Embolism

    • Intubated patient: GDOPE


    Pearls of diagnositic imaging l.jpg
    PEARLS of diagnositic imaging

    • Oral Contrast and CT abdomen

      • Theoretic increase in pick up of small bowel perforation and pancreatic injuries

      • Increases risk of vomiting and aspiration

      • Evidence doesn’t support that it increases sensitivity of CT for bowel injuries

        • ?Why: doesn’t get past stomach

      • Oral contrast OK but do NOT delay the CT in a patient that needs it sooner than later


    Head injured drunk combative what sedative would you use l.jpg
    Head injured, drunk, combative: what sedative would you use?

    • Midazolam: risk of hypotension and respiratory depression

    • Haldol: theoretical risk of lowering seizure threshold, longer duration

    • Haldol probably preferred


    What comes first head or belly l.jpg
    What comes first: head or belly?

    • CASE: Hypotensive trauma patient that needs laparotomy and has blown left pupil and signs of head trauma

    • What comes first?

      • To OR for laparotomy: pack off bleeding

      • Burr hole in OR (“blind”) or go back to CT for CT head

      • In general, belly comes first


    The trauma arrest l.jpg
    The TRAUMA ARREST

    • What type of rhythm is usually present?

    • What is your approach to the PENETRATING trauma arrest?

      • Thoracotomy if ever had vitals

    • What is your approach to the BLUNT trauma arrest?


    The trauma arrest26 l.jpg
    The TRAUMA ARREST

    • Intubate: crash intubation, no drugs

    • Ventilate: hyperventilate

    • Volume: blood through bertha

    • Needle the chest

    • CPR/Epi/atropine

    • Run for 5 – 10 minutes

    • NO thoracotomy


    How to manage the trauma room l.jpg
    How to MANAGE the trauma room

    • Should be ONE leader: only leader should be talking and giving orders

    • Too many “cooks in the kitchen” is bad

    • RTs and RNs need to stick to their roles

    • Be decisive

    • Err on the side of being aggressive

    • Move rapidly if the patient is sick

    • CXR and pelvic Xray BEFORE trauma labs, ABG, foley, NG, Cspine Xray


    The trauma question on the exam l.jpg
    The Trauma question on the exam

    • Same approach

    • Be methodological

    • Stick Man


    Key points29 l.jpg
    Key Points

    • Have a systematic approach to trauma

    • Have a systematic approach to the hypotensive and hypoxemic trauma patient

    • Be ready for the trauma arrest

    • Manage the trauma room


    ad