Revision 7, trauma management Flashcards
Primary and secondary survey when dealing with trauma patients (also when to operate)
Without excess time-wasting
Primary survey :
- 1) Assessment of the respiratory and cardiovascular systems
- Airways
- Breathing
- Circulation
- Disability (neurological evaluation)
- 2) Assessment of the central nervous system and urinary track system
Secondary survey:
- 3) Assessment of all other systems once the immediately life- threatening problems (identified during primary survey) are dealt with
- Complete physical examination
- Identification of all trauma-associated injuries
Trauma-associated thoracic injuries
Blunt thoracic trauma
* Vehicular trauma (most common)
* Animal-animal and human-animal interactions
* Falls from a height
- Most managed conservatively (blunt)
Penetrating thoracic trauma (less common)
* Animal-animal interactions
* Projectile injuries, impalements
- Surgical emergencies after medical stabilization (penetrating)
Clinical signs in respiratory compromised patients
- Increased respiratory rate and effort (also sounds)
- Restlessness
- Extended head and neck
- Abducted elbows
- Paradoxic movement of the chest and abdominal walls
- Unwillingness to lie down/on one side
Approach if lung sounds are decreased dorsal to diffuse in resp. compromised patient
Suspect pleural space injury
Rule out pneumothorax
1. provide oxygen support
2. perform thoracocentesis 9th-11th rib space bilaterally in dorsal 3rd of chest
3. 3-view thoracic xrays when medically stable
Approach if lung sounds are decreased ventral to diffuse with concurrent signs of hypovolemia in resp. compromised patient
Rule out hemothorax
1. provide oxygen support
2. perform thoracocentesis 5th-7th rib space bilaterally in ventral 3rd of chest
3. 3-view thoracic xrays when medically stable
4. consider tube thoracostomy
Approach if lung sounds are decreased ventral to diffuse +/- borborygmi in resp. compromised patient
Rule out diaphragmatic hernia
- oxygen support
- stabilize medically
- 3-view thoracic xrays when stable
Approach if lung sounds are increased in resp. compromised patient
Suspect pulmonary injury
Evaluate for referred upper airway sounds
Increased lung sounds originate from lungs and lower airways:
Rule out pulmonary contusion
- oxygen support
- confirm pulmonary contusion through 3-view thoracic xrays when stable
Approach if normal auscultation with severe increase in respiratory rate and effort
Rule out concurrent pneumothorax and pulmonary contusion
- oxygen support
- thoracocentesis 9th-11th rib space bilaterally in dorsal 3rd of chest
- confirm pulmonary contusion though 3-view thoracic xray when medically stable
Pneumothorax
Trauma associated pleural space injury
- Accumulation of air in the pleural space
- One of the most common trauma-associated thoracic injuries
- Open/closed (closed more common)
- Diagnosis: clinical examination/auscultation → thoracocentesis (U/S?)
- Radiography contraindicated in clinically significant cases!
Treatment:
1. Thoracocentesis
2. Oxygen
3. AB (open)
4. Thoracostomy tube placement if necessary
5. Surgery (open/recurrent pneumothorax 3-4 days or suspected tracheal avulsion/rupture)
Pleural effusion
- A buildup of fluid in the pleural space (many causes; in case of blood or chyle – possibly caused by trauma)
- Can be hemo- or chylothorax
Thoracocentesis
Equipment:
1. Syringe, 3 way stopcock, IV extension tubing
2. Needle
- Sternal recumbency
- Clip and prepare, aseptic technique
- Insert needle dorsally for pneumothorax, ventrally for effusion
- Stay close to cranial edge of the rib
- Aspirate
- Effusion – collect fluid for analysis
Trauma-associated abdominal injuries
- Surgery indicated in case:
- Evidence of septic peritonitis
- Any form of penetrating injury
- Evidence of unremitting (hellittämätön) intraperitoneal hemorrhage
- Any evidence of a traumatic body wall hernia that contains herniated abdominal viscera
- In all cases, thorough exploratory laparotomy necessary
- Decision to operate: after stabilization/weak patient
Ascites, abdominocentesis
Ascites:
* Abnormal accumulation of fluid (trauma-associated: blood, septic exudate, urine, bile, chyle) in the peritoneal cavity
- Abdominocentesis may be performed with or without (blind) ultrasound guidance in case of ascites
- Ultrasound guidance usually the preferred option
- Only confirmed fluid pockets are punctured
- Open/closed technique
- Similar equipment as for thoracocentesis
- Fluid always collected and analyzed
