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Contents:
(Assessment and management occur simultaneously. Do NOT proceed to Secondary Survey until ABC's are stable.)
CERVICAL SPINE Always apply a hard collar Airway first - if it is difficult to manage the airway with a collar in situ, have an assistant maintain head in neutral position and remove collar to intubate. AIRWAY In trauma airway problems are due to: 1. Decreased level of consciousness secondary to trauma, cerebral hypoxia, alcohol 2. Local trauma, foreign body, burns ASSESSMENT Talk to patient - look in the mouth/oropharynx Stridor Cyanosis Decreased level of consciousness TREATMENT Administer 100% °2 in every case. Try chin lift, jaw thrust Guedal oral airway Suction Intubation + Ventilation N.B. # Unless extremely urgent and patient is unresponsive, use induction agents and muscle relaxants when intubating, particularly for head injuries. Use in-line traction to immobilise the head and neck. All intubated patients should be ventilated # Use oral not nasal intubation. If problems are anticipated, get help. # Remember surgical airways - cricothyroid, minitrach or large bore cannula. BREATHING LIFE THREATENING PROBLEMS Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail Chest ASSESSMENT
TREATMENT 12g cannula into second intercostal space mid clavicular line if tension pneumothorax is suspected. If the patient is in extreme distress, suspect and treat for tension pneumothorax, prior to applying positive pressure ventilation. Forrnal thoracostomy can be inserted later. CIRCULATION Hypovolemia is the commonest cause of shock in trauma Control life threatening haemorrhage Occult blood loss may be:
FLUIDS Give colloids promptly and in large volumes through a warmer. Resuscitate not only the BP and pulse but also the urinary output, peripheral return and gut. Remember the ABG pH is a valuable guide. BLOOD Uncrossmatched - O+ve available immediately in Emergency blood fridge Group specific - 15 minutes Cross matched - 30 minutes Ambulance officers have often given large volumes of colloid. Give blood early. LINES Large peripheral lines are best. Insert 2 large bore cannulas. Use rapid infusion device to dilate ambulance drips. Intraosseous needles may also be used in children younger than 12. Do not put in central lines acutely. Provided no IVC disruption, femoral lines may be used. ONGOING ASSESSMENT Stable with maintenance fluid only - observe Stable with ongoing colloid - observe closely, preferably in ICU or HDU. Unstable despite ongoing colloid - reassess - consider early operation OTHER CAUSES OF SHOCK IN TRAUMA CARDIOGENIC
- NEUROGENIC High cervical cord lesion Decreased blood pressure, decreased heart rate and peripherally vasodilated DISABILITY Determine if there is any neurological deficit. Assess the GCS. EXPOSE Expose the patient Perform log roll and examine the back Attend to PR examination. This should be done prior to male catheterisation. HISTORY Try and get as full a history as possible from relatives, ambulance officers, police etc. e.g. time, accident, speed, thrown from car? If the patient is conversant, the history is useful and provides a good assessment of mental state.
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