Approach to Trauma Patients

Approach to trauma patients

Definition

  • Physical injuries of sudden onset and severity which require immediate medical attention.

Epidemiology

  • Trauma is a leading cause of death and disability in the world1
  • For every person killed by injury, around 30 times as many people are hospitalized and 300 times as many people are treated in hospital emergency rooms and then discharged. The mortality rose from 35% in a high-income setting to 55% in a middle-income setting, to 63% in a low-income setting. The loss of productivity due to death and disability from injury represents a significant loss of economic opportunity in all countries2

Approach to trauma victims at primary care center 

Introduction

  • Purpose: early recognition of severe injuries which r life threatening or potentially; initiate life saving measures and stabilize; facilitate transport of victims to higher tier trauma centers.
  • Most trauma related mortality are due to hemorrhage which is preventable.

Trimodal patterns of trauma mortality.

  1. Immediate, Early, Late

We cannot prevent immediate mortality; but early ones can be intervened by prehospital care; which is pioneering in our set up.

Late mortality is caused by organ failure and sepsis (potentially preventable) and early intervention.

Approach at our ED

A+C – Airway and cervical spine

  • Can the patient speak to you? If yes, airway is patent and protected.
  • Is the patient having secretion, stridor, wheezing, … if yes suck out the secretion, clear air way, open airway with jaw thrust or chin lift, place Oropharyngeal airway
  • Don’t rely on gag reflex to establish patency and protection of airway.
  • Apply cervical collar or sand or saline bag so as to prevent further damage to spinal cord and facilitate transportation during referral.

Applying cervical collar, measurement and steps (taken from Nursekey.com)

You can immobilize the patient over stretcher by applying saline bags and tie it as above.

B – Breathing

  • No spontaneous respiration? You are not feeling for air moving, chest raise? Decreased or absent air entry? Labored breathing? Gasping or agonal (ineffective) breathing? If one of these is yes, your patient needs your help on breathing.
  • Put on oxygen, start high and deescalate accordingly.

C- Circulation

  • Any visible bleeding, elevate, compress mechanically, if scalp just place sutures or if not possible appose the edges one over the others. Pelvis (antishock sheet bandage as shown below.
  • Where can the patient bleed to? The four and floor [abdominal, chest, pelvis, long bones) and external bleeding
  • Refer earlier, if you suspect bleeding.

D – Disability

  • Mental status, pupillary reaction (if not reactive, anisocoric or sluggishly reactive – seek help earlier) and RBS.
  • Interventions: Load mannitol, elevate head of bed, remove any tourniquet around the neck. (Use lasix if mannitol is not available 3). Refer for craniotomy

E – Exposure

  • Expose the patient, prevent hyperthermia, and use warm blankets and warm crystalloids!

Remember deadly triads (hypothermia, coagulopathy and hypotension)

We can prevent hypothermia!

Coagulopathy is caused by

  • Bleeding associated with loss of coagulation factors and is compounded by fluid we administer causing dilution of factors!) So, we can prevent this too.
  • What should our approach to resuscitation should look like? Permissive Hypotension! Whereby we target the low to normal MAP of 60 mmHg and permit some hypotension. Don’t give more than 2 bags to adults with polytrauma. If possible initiate blood transfusion after the pt fails to respond to the first 2 bags. And remember transfusion itself should be balanced! The pt needs platelet and fresh frozen plasma. This is best done in tertiary hospitals and refer ur patient early with communication.

And damage control resuscitation and surgery are continuum of permissive hypotension.

If you are in the primary care center and the patient will be transferred to better set up manage wounds accordingly.

  • Before you manipulate the wound let you start prophylactic antibiotics. Choice and route of administration as follows:
  • Table 1: risk assessment
 High riskLow risk
1Tears/bruises/contusion woundsMissile injury
2Bite woundsAdult
3Wounds contaminated with soil and dirt, or fecesChild
4Engagement of deep tissues, exposed fractureStraight stab wounds
5Wound with crush injuries 
6Wounds with the presence of foreign bodies 
7Elderly (>65 years) 
8Immunocompromised  

Table 2. Antibiotic prophylaxis for system-based trauma

  Recommendation
 Abdominal traumaPenetrating injuriesPiperacillin-tazobactam, in our case ceftriaxone and metronidazole
Blunt injuriesOnly if surgery is planned
 Traumatic brain injuryOpen or depressed skull fractures, pneumocephalus Meningeal dose, ceftriaxone
 Chest traumafirst-generation cephalosporin for penetrating chest injury
 Open fracturesGA I – cephalexinGA II and III– Ceftriaxone with gentamycin Add metronidazole if soil contamination

(Why before manipulation? To attain good serum level earlier).

2. Wash the wound thoroughly

3. TAT (After skin test), for children below five and pregnant or women who gave births and had ANC follow up and took TAT vaccine no need to administer TAT.

References

  1. WHO, Geneva 2016
  2. Jucá Moscardi, M.F., Meizoso, J., Rattan, R. (2020). Trauma Epidemiology. In: Nasr, A., Saavedra Tomasich, F., Collaço, I., Abreu, P., Namias, N., Marttos, A. (eds) The Trauma Golden Hour. Springer, Cham. https://doi.org/10.1007/978-3-030-26443-7_2
  3. Lorenzo AV, Hornig G, Zavala LM, Boss V, Welch K. Furosemide lowers intracranial pressure by inhibiting CSF production. Z Kinderchir. 1986 Dec;41 Suppl 1:10-2. doi: 10.1055/s-2008-1043386. PMID: 3811613.

By Dr. Shallo Alemu (Year one Emergency and Critical Care Resident at SPHMMC)

https://www.linkedin.com/in/shallo-alemu-md-4225221aa/

June 10, 2022 G.C

Finfinnee, Oromia

2 thoughts on “Approach to Trauma Patients”

Leave a Comment