ABC’s of Multi System Trauma

Christopher Freeman M.D.

Multi system trauma

 Invention of Motor Vehicles  High Forces  Multiple Injuries

Multi system trauma

 The most dramatic injury usually is NOT the most dangerous  Primary Survey  Secondary Survey  Re-evaluation

Initial Management

 Airway  Breathing  Circulation  Disability  Exposure  Correct problem before moving on

Airway

 Assess for Patency  Look  FB in Airway  Blood/Vomit/Secretions  Listen  Noisy Breathing = Obstructed Breathing  Normal speech = No Obstruction  Feel  Tracheal Location and Midline Shift

Airway Obstruction

 Be Vigilant with  Maxillofacial Trauma  Neck Trauma  Laryngeal Trauma  Nonverbal Patients

Airway Interventions

 Remove FB/Secretions/Emesis  Chin lift/Jaw Thrust  Oral/Nasopharyngeal airways  Reassess after interventions  Maintain C spine precautions

Breathing

 Open airway = Ventilation  Look  Chest rise/Symmetric movement  Listen  Symmetric and adequate BS/Adequate rate  Feel  Crepitus

Breathing

 Danger Signs  Respirations <10  Respirations >24  Poor Chest Rise  Labored breathing  Crepitus

Breathing

 If inadequate ventilation/airway  BVM  2>1  LMA  Combitube  ET intubation

Breathing

 Remember:  If Adequate BVM +/- Intubating  All trauma patient deserve Oxygen  Face mask is best  Protect the Spine

Circulation

 Look  Skin Color  Listen  BP  Late sign  Level of Consciousness  Feel  Pulse  Perfusion

Circulation

 Interventions  IV  Fluids  Control Hemorrhage  Tourniquet  patient uncontrolled bleeding in unstable  Reassess after interventions

 GCS  APVU

Disability

Exposure

 Remove from toxic exposures  Remove wet clothing  Prevent hypothermia  Expose for exam

Secondary Survey

 After primary  If stable  No Secondary  No problem

Multiple Trauma

 Goal  Stabilize patient and transport to definitive care  Definitive Care unstable patient  OR  Minimum time on scene  Maximum treatment in route  Continue reassessment  ABC’s

Case 1

 20’s y/o M, single car MVA into tree, ejected, found on ground, unresponsive

 Look  Blood in airway  Listen  Gurgling  Feel  Midline trachea

Airway

Airway Intervention

 Suction  Jaw thrust/Chin lift  Reassessment  Clear respirations, No FB present in airway

Breathing

 Look  Symmetric, adequate chest rise, no paradoxical movement  Listen  Rate 20, equal BS B/L  Feel  Crepitus over L chest Wall

Breathing Intervention

 ???

 Crepitus  No respiratory distress

Circulation

 Look  Pale, no obvious bleeding  Listen  100/60, Arousable to stimuli  Feel  HR 130’s, Cool to touch

Circulation Intervention

 Place 2 Large bore IV  Bolus 2 L NS  Reassess Vitals

 GCS  Eyes 2  Verbal 3  Motor 5  Total 10

Disability

Exposure

 Wet clothes removed  No obvious limb injury  Blanket applied

Reassessment

 Airway  Gurgling  Suction with improvement  Breathing  RR 34, Decreased BS on L, L sided Crepitus…

Diagnosis

 Tension Pneumothorax

Breathing Intervention

 Needle Decompression L chest Wall

Reassessment

 Airway  Clear, no gurgling, trachea midline  Breathing  RR 20, Equal chest expansion, good chest wall rise  Needle 2 nd intercostal space midclavicular line  Circulation  HR 110, BP 110/70, Skin Warm/Well perfused

Secondary Survey

 Blah, Blah, Blah

Disposition

 To ED, Stable  Admitted  Concussion  R CT, PTX/HTX  Grade 3 liver laceration  D/c from hospital 1 week later

Case 2

 27 Y/O MCA into Car  Unhelmeted, thrown from vehicle  Found on ground  Bystander called EMS

Airway

 Look  Blood in airway  Listen  Gurgling respiration  Feel  Midline trachea

Airway Intervention

 Suction  Jaw thrust/Chin lift  Oropharengeal Airway placed  Reassessment  Quiet, No FB present in airway

Breathing

 Look  Symmetric, Poor chest rise, no paradoxical movement  Listen  Rate 6, diminished BS B/L  Feel  Crepitus over B/L chest Wall

 BVM

Breathing Intervention

Breathing Reassessment

 Look  Symmetric, Poor chest rise, no paradoxical movement  Listen  Rate 18 by BVM, diminished BS B/L  Feel  Crepitus over B/L chest Wall

Breathing Intervention

 B/L Needle Decompression

Breathing Reassessment

 Look  Symmetric, Adequate chest rise, no paradoxical movement  Listen  Rate 20 by BVM, equal BS B/L  Feel  Crepitus over B/L chest Wall

Circulation

 Look  Pale, Bleeding from LLE, LUE  Listen  80/50, unconscious, unarousable  Feel  HR 140’s, Cool to touch

Circulation Intervention

 Place 2 Large bore IV  Bolus 2 L NS  Pressure on bleeding sites  Reassess Vitals

Circulation Reassessment

 Look  Pale, Persistent bleeding LLE, Bleeding controlled LUE  Listen  80/50, unconscious, unarousable  Feel  HR 150’s, Cool to touch

Circulation Intervention

 Tourniquet to LLE

 GCS  Eyes 1  Verbal 2  Motor 4  Total 7

Disability

Exposure

 Wet clothes removed  Limb deformity, Bleeding LUE, LLE  Blanket applied

Reassessment

 Airway  Oropharngeal Airway in place, No FB  Breathing  RR 20, Decreased BS on B/L, Increased Airway resistance

Intervention

 Chin Lift/ Jaw Thrust  Oral Suction  Needle decompression

Reassessment

 Airway  Oropharngeal Airway in place, No FB  Breathing  RR 20, Equal BS on B/L, Normal resistance  Circulation  HR 120’s, BP 90/50, Bleeding controlled with tourniquet

Secondary Survey

 Not Done prior to arrival

Disposition

 To ED, Unstable  Arrest In ED  ED Thoracotomy  Unsuccessful

 Keep it Simple  ABC’s

Summary

 Airway Management = Intubation  Minimize time to Definitive treatment  OR

Questions?