Trauma basics - 2

Important Hypoxia and hypotension kill head-injured patients.   
 

Resuscitation

Resuscitation should be carried out as the primary survey is occurring.

If a problem is found, it should be fixed immediately, and the primary survey repeated again, from the beginning.

The team leader should repeat the primary survey if the patient deteriorates at any stage.    
 

Airway management

takes precedence over everything else.
- Position patient and clear mouth and pharynx manually and with suction.
Gently extend the head (REMEMBER THE CERVICAL SPINE) and perform jaw thrust or chin lift.     
 

 Indications for intubation in major trauma

1. Obstructed (or potentially obstructed) upper airway.
2. Mechanical impediment to ventilation not correctable by posture or clearing mouth & pharynx.
3. Persistent circulatory shock.
4. Hypoxia despite supplementary oxygen.
5. Major multiple injuries requiring large amounts of sedation and analgesia, especially if patient requires transportation.
6. Excessive combativeness or inability of patient to cooperate.
7. Glasgow Coma Score less than 9.    
 

 tubed

Breathing

Recognise and treat mechanical impediments to breathing:
- Tension pneumothorax.
- Flail segment.
- Open chest wound.    


Tension pneumothorax

This is a clinical diagnosis, not a radiological one. The chest X-ray below is one that should never be done.

Insert 16 gauge cannula into 2nd intercostal space in midclavicular line of the side that the trachea is pushed away from. A rush of air should escape, oxygenation should increase and the trachea should return to the midline.
If none of the above occurs, you have just created a pneumothorax. Either way, an intercostal catheter should be inserted.    

 thorax

 

 Even more inappropriately, a tension pneumothorax on CT:    

 

 ct pt

 

Flail segment

A flail segment is a section of the chest wall that moves paradoxically (moves inwards when it should be moving out) in inspiration. The usual reason is multiple rib fractures.
Intubation is often necessary to maintain good oxygenation, although theoretically CPAP should work. Either of these treatments may turn a simple pneumothorax into a tension pneumothorax.    
 

Open chest wounds
 

These should be covered with a dressing with tape on three sides: the aim is to produce a one way valve to prevent air being drawn back into the wound.
Alternatively an occlusive dressing may be placed over the wound and a chest drain inserted.    
     
 

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