TRAUMA LIFE SUPPORT

 Initial Resuscitation of Trauma Patients:

 Objectives
 to discuss trauma epidemiology
 to give an overview of the 4 phases of trauma care
 to discuss specific measures in trauma management
Philosophy of Trauma Care

 The physician must treat as he/she gathers

information
 Therapeutic interventions are made even
before a full evaluation can be completed
 The management is not linear, but should be
viewed as a progression through a series of
loops
 Examines >>>acts on a positive findings >>> checks
the effects >>>progresses to the next loop
Philosophy of Trauma Care

 Auto Accidents
 Falls
 Mugging, Knifing, Shooting
 Occupational
 Recreational
Statistics in Trauma

 Trauma in the US
 Most common causes of death in persons aged 1 to
44 years old
 4th leading cause of death in all individuals
 About 50% die in the scene of accident from major
vascular and neurologic injuries
 About 30% die within the first few hours as a result
of irreversible shock and intracranial hematomas
Statistics in Trauma

 Trauma in the Philippines

 5th leading cause of mortality
 5X more common in males
 Causes 8.5% of all deaths
3 Peaks of Traumatic Death

 Peak 1 - Within seconds of injury

 Massive head injury
 Heart Injury
 Aortic injury

 Cannot be prevented
3 Peaks of Traumatic Death

 Peak 2 - An hour or two after injury

 Subdural and epidural injury
 Hemo or pneumothorax
 Organ rupture
 Blood loss

 GOLDEN HOUR - prompt intervention saves lives

3 Peaks of Traumatic Death

 Peak 3 - Days after injury

 Sepsis
 Multi-organ failure

 Prompt treatment of shock and hypoxemia during

the GOLDEN HOUR can reduce these deaths
PHASES

 Phase 1 : Primary Survey

 Phase 2 : Resuscitation
 Phase 3 : Secondary Survey
 Phase 4 : Definitive Care
Phase 1 : Primary Survey

 Goal :
Identify injuries that pose an imminent threat to the
patient’s survival and simultaneous management
is begun
Phase 1 : Primary Survey

 Assess:
1. Airway control with C spine protection
2. Breathing adequacy
3. Circulation adequacy with hemorrhage control
4. Neurologic disability
5. Exposure
Airway control with C spine
protection
 assess patency of upper airway
 jaw thrust maneuver
 removing foreign debris
 specific attention for possibility of cervical
spine fracture
 excessive movement can convert a fracture
without neurological damage into a fracture
dislocation with neurologic injury
Airway control with C spine
protection
 Assume cervical spine fracture in any patient with
an injury above the clavicle
 Neurologic examination alone does not rule out a
cervical spine injury
 Integrity of the cervical spine must be assessed (all
seven cervical vertebrae must be visually
examined)
 crosstable lateral cervical spine x-ray
 Swimmers view
Breathing

 Chest should be exposed to adequately

assess ventilatory exchange
 Airway patency does not assure adequate
ventilation
 Adequate air exchange is necessary in
addition to an open airway, full sufficient
oxygenation
Breathing

 Bag-valve device connected to a mask or to

an endotracheal tube

 Three traumatic conditions that compromise

ventilations
 tension pneumothorax
 open pneumothorax
 large flail chest with pulmonary contusion
Circulation adequacy with
hemorrhage control
 Obtain information regarding peripheral
perfusion and oxygenation (pulse, skin color
& capillary refill)
 Pulse
 quality
 rate
 regularity
Circulation adequacy with
hemorrhage control
 Pulse
 Site
 Radial Pulse - systolic pressure will be above 80
mm Hg
 Femoral Pulse - systolic pressure will be above 70
mm Hg
 Carotid Pulse - systolic pressure will be above 60
mm Hg
Circulation adequacy with
hemorrhage control
 Peripheral Perfusion
 Capillary Blanch Test
 done on hypothenar eminence, thumb or toenail
bed
 normovolemic patient - color returns to normal
within two seconds
Circulation adequacy with
hemorrhage control
 Direct pressure on wounds
 Pneumatic splints
 Tourniquets
 produce anaerobic metabolism
 increased blood loss
Direct Pressure on wounds
Circulation adequacy with
hemorrhage control
 Occult hemorrhage can account for large
amount of blood loss
 thoracic or abdominal cavities
 muscle body surrounding a fracture
 penetrating injury
Neurologic disability

 rapid neurologic evaluation

 establishes patient’s level of consciousness and
pupillary size and reaction
 AVPU (Level of consciousness)
 A - Alert
 V - Response to Vocal Stimuli
 P - Response to Painful stimuli
 U - Unresponsiveness
Neurologic disability

 detailed quantitative neurologic examination

 Glasgow Coma Scale
Neurologic disability

 Neurologic condition that varies from the

primary survey to the secondary survey
 a change in the intracranial status may be
indicated

 Decrease in the level of consciousness may

indicate
 decreased cerebral oxygenation and or perfusion
Neurologic disability

 Changes in the neurologic status

 immediate re-evaluation of patients’
oxygenation and ventilation status
Exposure

 Patient should be completely undressed to

facilitate through examination and
assessment

 Provide your patient Visual and Auditory

Privacy at all times
Phase 2 : Resuscitation

 Life -threatening conditions identified in the

primary survey are constantly reassessed and
management continued
 Tissue aerobic metabolism is assured by perfusion
of all tissue by well oxygenated RBC (Fick
Principle)
 Replacement of lost cardiovascular volume by
crystalloid fluids and blood is begun as are other
modalities of shock therapy
Phase 2 : Resuscitation

1. Supplemental O2, preferably by mask at

12LPM
2. Vascular access, large bore needles
3. Fluid replacement
4. Cardiac Monitoring
5. Bladder and Nasogastric Catheter Placement
- if not contraindicated
Fluid Management

 Isotonic electrolyte solutions

 Lactated Ringers’ - closely approximates Plasma
concentration - Fluid of Choice
 Normal Saline
 Plasmalyte A
 Hypertonic solutions
 Plasma Expanders
Fluid Management

 Fluids Characteristics
Dextran Rapidly expands plasma volume
Normal Saline Raises intravascular volume
Replaces body fluids
Mannitol Raises intravascular volume
Reduces interstitial and intracellular edema
Promotes osmotic diuresis
Lactated Replaces body fluids
Ringers' Provides additional K and Ca
Buffers acidosis
D5 Water Raises total body water
Provides 200 calories/liter
Fluid Management

 Adequacy of fluid resuscitation

 Amelioration of clinical signs of shock
 Return of stable vital signs, including central
venous pressure
 Urine output greater than 50 cc/hr
 When the shock state fails to resolve in 15
minutes of aggressive fluid resuscitation,
consider hemorrhage or coexisting cause of
shock
Pharmacologic Therapy

 Dopamine
 Dobutamine
 Epinephrine
 Norepinephrine
 Na Bicarbonate
Pharmacologic Therapy

 Dopamine
 Stimulates α,β and dopaminergic receptors
Dose : 2 - 10 mcg/kg/min
 Has predominantly inotropic and chronotropic
activity by direct β stimulation
 Stimulates release of endogenous norepinephrine
Pharmacologic Therapy

 Dobutamine
 Symphatomimetic through β receptor
 Lacks significant vasoconstrictive properties
 Mild vasodilative effects
 Drug of choice for myocardial support
Pharmacologic Therapy

 Na Bicarbonate
 Patients in shock develop metabolic acidosis due
to inadequate tissue perfusion and oxygenation
 Effects of acidosis
 Depresses myocardial contractility
 Decreases response to inotropic agents
 Acidosis usually responds to fluid replacement
Pharmacologic Therapy

 Na Bicarbonate
Too much Bicarbonate
 Produces acidosis
 Shifts the O2 dissociation curve to the left
 Na overload - congestion
 Elevated serum osmolarity
 Hypokalemia
 Reduced ionized calcium
Phase 3 : Secondary Survey

 Goal
Comprehensive evaluation for detecting less
obvious injuries not apparent during the
primary survey

 Does not begin until the primary survey

(ABCs) has been completed and the
resuscitation phase has begun
Phase 3 : Secondary Survey

 In-depth evaluation
 evaluating the body by sections (head, neck,
chest, abdomen, extremities and neurologic)
 stethoscope used over each body cavity and major
vessel
 palpate for bony defects
Phase 3 : Secondary Survey

 Includes
 Head-to-toe exam
 History
 Radiologic exam
 Laboratory testing
Phase 3 : Secondary Survey

 History
 Ask for information about the trauma scene
 Ask patient (if able), close relatives and friends
 Inquire about the events (and mechanism) of
injury
 Allergies
 Last meal
 Surgical scars
Phase 3 : Secondary Survey

 Physical Exam
 Interrupt the exam to manage potentially life
threatening injuries
 Every inch of the patient is viewed and palpated
 Laboratory testing
 Baseline Blood count
 Urinalysis
 Electrolytes
 Bleeding parameters
 Blood type and crossmatch
Phase 3 : Secondary Survey

 Radiologic Exam
 “X- ray everything that hurts”
 X-rays do not take precedence over treatment of
life threatening conditions
 Chest and cervical spine x-ray are obtained as
soon as the patient is stabilized and take
precedence over subsequent roentgenographic
evaluation
Phase 3 : Secondary Survey

 Temper with the thought that the extra cost of

“unnecessary” tests is trivial compared to the
overall expense of treating trauma patients.
 The cost of delayed diagnosis associated with
NOT ordering routine tests can be substantial.
Phase 3 : Secondary Survey

 Special Exams
 CT scans / MRI / Nuclear Medicine
 Endoscopic procedures

 Done only when benefits outweigh risks

 Take the patient out of the Emergency Room
 Not to be done while potentially unstable
Phase 4 : Definitive Care

 patient’s less life-threatening injuries are

managed
 in-depth management
 fracture stabilization and splinting
 necessary operative intervention
 stabilization of patient in preparation for transfer
Revised Trauma Score

 Glasgow Coma Scale (GCS)

 Systolic Blood Pressure (SBP)
 Respiratory Rate (RR)

Champion HR, et at, A revision of Trauma score. J Trauma

1989 May; 29 (5); 623 - 9
Revised Trauma Score

 Glasgow Coma Scale (GCS)

Eye Opening Verbal Motor
4 - Spontaneous 5 - Oriented 6 - Obeys Command
3 - To voice 4 - Confused 5 - Localizes
2 - To pain 3 - Inappropriate 4 - Withdraws
1 - None 2 - Incomprehensible 3 - Flexes
1 - None 2 - Extends
1 - None
Champion HR, et at, A revision of Trauma score. J Trauma 1989 May; 29
(5); 623 - 9
Revised Trauma Score

 Glasgow Coma Scale

Convert
13 - 15 = 4
9 - 12 = 3
6- 8 = 2
4- 5 = 1
<4 = 0

Champion HR, et at, A revision of Trauma score. J Trauma 1989 May; 29

(5); 623 - 9
Revised Trauma Score

 Systolic Blood Pressure (SBP)

 Measure systolic blood pressure in either arm by
auscultation or palpation
More than 89 = 4
76 - 89 = 3
50 - 75 = 2
1 - 49 = 1
0 = 0
Champion HR, et at, A revision of Trauma score. J Trauma 1989 May; 29
(5); 623 - 9
Revised Trauma Score

 Respiratory Rate
Count respiratory rate in 15 sec, multiply by 4
Respiratory Rate Rate
> 29 4
10 - 29 3
6- 9 2
1- 5 1
0 0

Champion HR, et at, A revision of Trauma score. J Trauma 1989 May; 29

(5); 623 - 9
Revised Trauma Score

To obtain the trauma score, add the final scores

for respiration, systolic BP and convert
Glasgow Coma Score
12 = .995 8 = .667 4 = .333
11 = .96 7 = .636 3 = .300
10 = .829 6 = .630 2 = .286
9 = .766 5 = .455 1 = .259
0 = 0.057
Champion HR, et at, A revision of Trauma score. J Trauma 1989 May; 29
(5); 623 - 9