MAJOR TRAUMA MANAGEMENT- AN INTRODUCTION Debkumar Chowdhury 

CONTENTS  Relevance to Emergency Medicine  Pitfalls  Management  The Lethal Triad of trauma  Paediatric trauma management- an overview  Diagnoses  Cases 

RELEVANCE TO EMERGENCY MEDICINE  Trauma – considered as one of the greatest ‘disease’ of our times- significant morbidity and mortality  A significant workload in the ED (even greater in MTC)  Basic measures instituted to ensure good outcome  TEAM approach is paramount  Central to all critical care specialties  Early recognition of physiological parameters 

PITFALLS  Failure to recognise clinical deteoriation and the appropriate documentation  Failure to recognise injuries – importance of primary and secondary survey (if possible)  Senior help not sought early  Team Leader(coordinates the various personnel) - its absence  Failure to gain overall control/insight  Survival intrinsically linked to good basic initial management  Getting vital information early- use AMPLE (Age, Mechanism, Past medical history, Last meal, Events around) 

MANAGEMENT  CABCDE  C-Catastrophic haemorrhage- Direct pressure, Occlusive dressings, tourniquet  A- all trauma patient HFO initially +C-spine immobilisation (triple immobilisation) (paediatric cases different)  B- assess ventilation and oxygenation  C- Establish- 2 large bore IV cannulae, EZ -IO if needed, Crossmatch , Baseline bloods, Analgesia, use of E-FAST if available  D- GCS, Pupil response  E- very important initially, beware of inducing hypothermia  Early imaging once patient stable  If unstable- damage control intervention 

PAIN- IMPORTANCE OF ITS MANAGEMENT  Psychological and physiological consequences  Pain- increases metabolic demands (oxygen requirements)  Modified WHO ladder  Consider IV analgesia early  IV paracetamol as an adjunct with IV opiates (especially limb injuries)  Effective pain management- leads to better outcome  Consider nerve blocks (if applicable) 

LIFE THREATENING DIAGNOSES  ATOMFC  Airway obstruction  Tension Pneumothorax  Open Pneumothorax  Massive Haemothorax  Flail Chest  Cardiac Tamponade 

MORE ON CIRCULATION  Don’t forget analgesia  Consider IV TXA (Tranexamic acid) early  If bleeding- then give blood- Replace blood with blood  Volume replacement- crystalloid – preferably Hartmann’s  Consider pelvic binder  Splint large bone fractures- reduces bleeding and pain  Monitor U/O- Catheterise(urethral) unless evidence of urethral injury (retrograde urethrogram) 

PELVIC BINDER  Prior to (and during) application, remember 3 Ps  Pain  Pockets  Penis  Ensure position over GT  Reduce bleeding- especially with open book fractures  Tamponade and close the pelvic ring 

THE LETHAL TRIAD OF TRAUMA  Hypothermia- direct effect on coagulation cascade- impaired PLT function, inhibiting clotting factors, inappropriate clot breakdown,  N.B. Warm Fluid/PRC prior to administration  Don’t forget to cover 

LETHAL TRIAD CONTINUED  Significant blood loss- Anaemia- Peripheral vasoconstriction(also due to hypothermia)- decreased Cardiac output (hypovolaemia)- Impaired oxygen delivery- increased anaerobic metabolism- metabolic acidosis (rising lactate levels)  Haemoglobin- oxygen carrying capacity- Low Hb = Low oxygen delivery to tissues  Cardiac output= Heart Rate x Stroke Volume  Severe hypothermia- Bradycardia + Severe acidosis- Negative ionotropic = Cardiovascular collapse 

PAEDIATRIC TRAUMA  High BSA in proportion to adults- Greater chances of hypothermia  Concerns about subluxation of C-spine  Larger occiput to body ratio- inadvertent C-spine hyper-extension  Uncuffed tubes (reduce tracheal stenosis, strictures)  Compensates well initially before haemodynamic collapse  Plasticity of bone (if #- high impact trauma/ injury to deeper structures)  Prepare team well early intervention of paediatricians 

SPOT THE DIAGNOSIS 

A FEW MORE 

SCENARIO 1  25 year old male whilst operating with heavy machinery had crush injury to thorax  Fit and Well- No PMHx/SurgHx  No regular medications  A- Patent, No C-spine injury  B- Tachypneoic (RR-20/min), auscultation- vesicular breath sounds  C- HR- 120, BP- 80/65  D- Alert, c/o pain in chest  E- Some bruising to the chest, no other identified injuries present 

INVESTIGATIONS Any other investigations? Imaging? 

INVESTIGATION RESULTS  Main biochemical abnormality Troponin- 0.50 (0.01-0.03)  Echocardiogram- Normal  Following analgesia- pain settled  Diagnosis?  Management? 

MYOCARDIAL CONTUSION  Difficult to diagnose  Associated with significant chest wall trauma  Associated with sternal fractures  Non-specific ECG changes  If ECG- Normal, Cardiac enzymes- Normal  Can safely rule out diagnosis  If suspected then needs Echo/ Myocardial perfusion scan  Acutely needs cardiothoracic input  Early ionotropic support following adequate fluid resusctiation 

SCENARIO 2  35 year old gentleman, standby with head injury  Fallen from a height of 20 feet  Previously fit and well  No PMHx/Surg Hx/No regular medications  SAS- Extensive bruising in the right parietal region of scalp, no occult bleeding present, Open fracture of the left Tibia/fibula  Trauma team – I+V  Family on route 

EXAMINATION FINDINGS  A- I+V, good pressure, tube position checked- no issues  B- On ventilator, 12/min  C- BP- 200/160 HR- 55  D- Prior to I+V, GCS 5/15, was becoming combative, Pupil reactive but sluggish, Right pupil 4, Left pupil 5  E- Left lower limb in a temporary splint  BM- 8, T- 36.5 Any immediate measures Management? 

ANY IMMEDIATE MEASURES 1) IV mannitol/ Hypertonic saline 2) Maintain PCO2 within normal limits (Immediate I+V) 3) Positionioning of patient 4) Avoid hypoxia and hypotension 5) Definitive management? 

MUNRO-KELLY PRINCIPLE  Skull is a box  Contains Brain, CSF and blood  If any of the above volume rises then  Brain has less space- will go through area of least resistance CPP = MAP-ICP CPP- Cerebral Perfusion Pressure MAP- Mean Arterial Pressure ICP- Intracranial Pressure SBP- Systolic Blood Pressure DBP- Diastolic Blood Pressure MAP= DBP+ 1/3(SBP-DBP) Cardiac output= Heart Rate x Stroke Volume CO = HR x SV Aim- Prevent Secondary Brain Injury 

SOME IMAGING 

BASIC ANATOMY 

TAKE HOME MESSAGES  Early assessment and management  Low degree of suspicion of additional injuries- undertake trauma imaging  Early normalisation of physiological markers  Ask for help early  Review and reassess  Leadership in trauma management