Issues in Trauma

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Issues in Trauma

• Lynne Fulton
• May 27, 2009

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Intro

• No basics
• My backround
• Demanded efficient and thoughful care by other
  team members
• Observing a patient is often more valuable than
  DOING SOMETHING

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OBJECTIVES

• DISCUSS
• CONTROVERSIES IN TRAUMA MANAGEMENT
• PENETRATING NECK TRAUMA
• UNUSUAL PROBLEMS
• GERIATRIC ISSUES
• QUESTIONS - for which I will not have answers!

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Controversies

• Fluid resuscitation and intubation in trauma
  patients
• Trauma 2nd most important condition for
  children and 4th most important for adults in
  pre-hospital care

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OPALS Major Trauma Study

• 2008, CMAJ
• Major trauma (ISSgt12)
• Adults (gt16 years)
• 17 urban centres
• Pre and post Advanced Life Support being
  introduced

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• 2867 patients
• Stats re age, sex, mechanism, injury severity
  matched
• Excluded Toronto and Hamilton, dead at scene,
  injuries 8 hours prior to EMS being called
• All treated at lead trauma hospitals

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• Previous study showed no impact on outcomes for
  patients with cardiac arrests
• Previous study showed improved outcome in
  patients with respiratory distress

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• Primary interventions were intravenous fluids and
  endotracheal intubation

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• No substantial difference in survival to
  discharge (81.8 for basic life support, and
  81.1 for advanced life support)
• No difference in early deaths (lt24 hrs)
• No difference in morbidity based on GCS and
  functional independence at discharge and 6 months

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• If GCS less than 9, survival was lower with
  advanced life support
• ALS associated with increased mortality,
  intubation associated with increased mortality,
  IV therapy associated with no change in mortality

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• Other studies have come to similar conclusions
• Penetrating torso injuries have increased
  survival, earlier discharge, and fewer
  complications with delayed fluid administration
• Increased compartment syndromes with aggressive
  fluid administration early in limb trauma

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?

• Rural versus urban situations
• Why
• increased scene time
• increased bleeding due to increased BP
• - hyperventilaton

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• Scoop and run seems more effective in urban
  settings

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Penetrating Neck Injuries

• 5-10 of traumatic injuries in US
• Increased incidence in Canada
• Mass casualty situations

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Zones

• Zone 1 clavicle to cricoid cartilage
• Zone 2 cricoid cartilage to angle of the
  mandible
• Zone 3 angle of the mandible to base of the
  skull

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Incidence by Zone

• Zone 2 most common
• Zone 1 second
• Zone 3 least

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Associated Injuries

• Aerodigestive tract
• 10 laryngeal or tracheal injuries
• 9.6 esophageal injuries
• Vascular - venous 9
• - Arterial 6.7

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• Zones can be transgressed

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Principles

• Immediate transfer to nearest trauma centre
• Do not remove projectile if present
• Do not explore the wound

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Airway

• Oral intubation preferred
• If airway injury is present (sucking wound or
  subcu emphysema or bubbling wound) bag valve mask
  can lead to problems

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• Consider chest injuries

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• Control bleeding with direct pressure
• Transport in position to allow adequate
  respirations
• A neuro deficit may be due to a vascular injury,
  and intact pulses do not rule out vascular injury

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Cases

• A 25 year old woman is struck by a car while
  standing at a bus stop, and thrown 20 feet. She
  is VSA. She is intubated and given epi (1 dose)
  and regains a pulse and blood pressure.
• What is her primary injury?

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Cases

• A young woman is a belted driver in a car
  involved in a minor motor vehicle accident on
  Bayview Avenue and her airbag deployed. She was
  DOA on arrival at the hospital.
• What happened?

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Cases

• A young man presented from a motor vehicle
  accident with a decreased level of consciousness
  and a laceration of his cheek.
• Ventilation was attempted with a bag valve mask,
  and was not successful.
• Why?

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Cases

• A head injured patient, who was hyperventilating,
  was nasally intubated, and aspirated the tube.
• What happened?

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Geriatric Issues

• Under-triage is the norm
• Outcomes are poorer
• Reflexes are slower
• Meds are more common