Trauma Surgery
[SHOCK]
Introduction Whenever dealing with a trauma patient, the priorities are the ABCs: Airway, Breathing, Circulation - in that order. Without a patent airway air is unable to move with breaths. Without breathing it’s impossible to deliver oxygen or remove CO2 there’s no point in having circulation. Therefore, the first step should be the evaluation of the airway. 1) Airway: an airway is considered patent if the patient is talking, coughing , or moving air. If the patient is gurgling (blood or fluid), there’s stridor (laryngeal edema), or has no air movement (apnea), then we must intervene. A patient may appear stable but requires prophylactic intervention in the case of an expanding hematoma or severe trauma . An airway is assessed with a head-tilt chin-lift and secured with an endotracheal tube or with cricothyroidotomy. Emergent tracheostomy should NOT be attempted in the ER, only in the OR. 2) Breathing: if there are bilateral breath sounds the patient is breathing adequately. A BVM or ventilator may be needed to assist ventilations. Monitor breathing with pulse oximetry and/or end-tidal capnography. 3) Circulation: shock is defined by any number of parameters. A Systolic Blood Pressure < 90 or Urine Output < 0.5mL/kg/hr or clinical signs of shock (pale, cool, diaphoretic, sense of impending doom ) is sufficient to diagnosis shock. Shock Shock in the traumatic setting has one of three causes. 1) Hemorrhage drains the tank. There is a hole somewhere that needs to be plugged. The patient will have flat veins and rapid HR to compensate. The most important thing to do is plug the hole in the OR. However, there may be transport time or prep time before the hole can be closed. In the meantime, start 2 large bore IVs (> 16 G ) and run fluids. First LR then Blood as it becomes available. See Resuscitation and Location to the right. 2) Tamponade is caused by severe blunt trauma that reduces cardiac filling. Blood backs up into the venous system so the patient presents with distended Neck Veins but clear lung sounds . Emergent pericardiocentesis (ER) or mediastinotomy/thoracotomy (OR) is required. 3) Tension Pneumothorax is caused by penetrating trauma and fills the pleural space with air or blood, compressing the veins feeding the heart. There are distended neck veins (like in tamponade) but there are reduced lung sounds on the affected side and tracheal deviation away from the lesion. Emergent needle decompression and chest tube (thoracostomy) is required.
Intervene Now
Airway Intervene Soon
Unconscious (GCS<8) Gurgling Stridor
Expanding Hematoma
Talking in full sentences
Cutaneous Emphysema
Coughing Good Air Movement
Managing the Airway OPA Avoid OPA in gag reflex NPA Avoid NPA in facial fracture fracture ET Tube Preferred Definitive Method NT Tube Avoid in facial fracture fracture Cricothyroidotomy If ET Fails, temporizing Tracheostomy Only in OR, Definitive
Monitor Intervene With
Breathing SpO2, ET-CO2 BVM, Ventilator, Oxygen
Circulation Shock = SYS BP < 90 or Uoutput <0.5mL/kg/hr Type Hemorrhagic Tamponade
Tension Pneumo Cardio genic Vasomotor Septic
Physical Flat Veins, Clear Lungs Engorged Veins, clear Lung Sounds Engorged Veins, ↓ Lung Sounds Engorged Veins, ↑ Lung Sounds Flushed, Pink, Warm Flushed, Pink, Warm
Path Active Bleeding Blunt Chest Trauma
Penetrating Chest Trauma
Tx IVF, Blood, Surgery Pericardiocentesis Pericardial Window Needle to Chest Tube
Massive MI
Inotropes
Spinal Trauma or Anesthesia Sepsis
Vasopressors Vasopressors and Abx
Hemorrhagic Resuscitation (1) Direct Pressure (2) Elevate Extremity (3) Arterial Tamponade (4) Tourniquet (5) 2 Large G IVs IO (6) IVF (Crystalloids) (7) Blood (8) Surgery
Do not be confused by some of the causes of non -traumatic shock No Intervention
© OnlineMedEd. http://www.onlinemeded.org
Trauma Surgery 1)
2)
3)
[SHOCK]
Cardiogenic shock occurs after a major MI and is a product of pump failure . Forward flow fails so blood backs up. There will be bilateral pulmonary edema and distended neck veins . This is the major differential against tamponade and tension pnuemo. Giving fluids can be fatal while the treatment is actually inotropes. Don’t get tripped up. Vasomotor shock is loss of sympathetic tone that keep the arteries constricted. There’s massive vasodilation everywhere; suddenly the tank is too big to be filled by what’s in the body. This occurs in spinal trauma or anesthesia. The patient will be pink, warm and dry with a low BP. Give back the tone with vasopressors and correct the underlying problem. Septic. Local cytokines increase blood flow (leukocyte delivery) and increase vascular permeability to fight local infection. Cytokines everywhere cause a variant of vasomotor shock, resulting in vasodilation (warm, pink, and dry). Identify the organism with blood cultures and treat with both vasopressors and antibiotics.
© OnlineMedEd. http://www.onlinemeded.org
