now because this is so important I'm
going to run through it on the notes so
the first priority a with C spine
protection we assess the patency of the
patient's Airway we look at the chest
movements we listen for the air going in
and out of the patient's nose and mouth
and we can feel for the air you can put
your hand
near the patient's mouth and feel the
air going in and out with your hand or
if they're breathing very quietly you
can put your ear down on the patient's
nose and that means you can look down at
their chest listen to the air and feel
the air on your ear at the same time so
we need to assess that if we're not
happy with it we need to consider
opening the
airway now the chin lift is not
appropriate in a trauma situation for an
unconscious patient because we can't
exclude a c-spine injury it is
appropriate in many medical situations
where we happy there is not a cervical
spinal
injury if we if there is a possibility
of cical spine injury we go for the ja
thrust maneuver and of course we can
also use air we adjuncts such as naso
farang Oro farang Airways lenal masks
but if we want to protect the airway
from aspiration the only Airway adjunct
that will do that is endot tral
intubation with an inflatable cuff that
will give us a patent Airway and Airway
protection the principle in trauma is
assume sepine damage until proved
otherwise and that is an x-ray of C1
down to C7 normally including t
1 in the AP the anterior posterior and
the lateral views and assessed by
someone very skilled in assessing x-rays
if at all possible a consultant
orthopedic surgeon and we use the
Trinity of
protection this is the hard collar
around about the neck the sandbags on
the side of the head and also taping the
forehead down onto the trolling the
three components of SE spine protection
the aim being to immobilize the head
relative to the rest of the
body if Airway obstruction is present we
want to identify it it could be foreign
material it could be the presence of
vomit we listen for
stridor stridor means noisy breathing
and if the glasgo Coma Scale is less
than eight we should
inate so a definitive Airway should be
established if there is any doubt that a
patient can maintain their own Airway
Airway and sepine control is our number
one priority our number one duty to
every traumatized
patient and also we can consider gastric
catheters probably a nasogastric
catheter with suction and this can
decompress the stomach because very
often in trauma the parasympathetic
nervous system is not working because of
the sympathetic overload and gastric
contents are not moved through the
stomach the stomach becomes distended
and vomit becomes lightly and vomit of
course has a risk of aspiration if the
level of Consciousness is low so at some
stage we can consider gastric catheters
with suction decompressing the stomach
making vomit and subsequent aspiration
of vomit less
likely thinking now about the next
priority breathing and
ventilation we'll expose the patient's
chest to assess them and we will observe
for bilateral chest movements if you
look at normal chest movements they
should be bilateral that's called the
chest Excursion so we're looking for
bilateral normal chest
Excursion oscal consultation we can
listen and the air sounds we should hear
the air going in all parts of the chest
as we listen there should be good a
entry into all parts of the
chest visual inspection the surface of
the chest for any injury and we can also
palpate it to see if we can feel any
injuries we can also beuss to see if
there's any dull or hyperresonant areas
as
well and what sort of injuries might be
compromising breathing and
ventilation well Numa thorax is air in
the
plural in the plal cavity the potential
space becomes an actual space that's a
possibility now if there's a flap of
tissue that means air can get into the
plural space but can't get
out and that means the pressure in the
plural space will build up causing a
tension num thorax particularly
dangerous because this will compress the
heart and the large vessels moving it to
one
side an open p thorax we can detect and
these are called sucking wounds because
you barely hear the air sucking in and
out of a hole in the side of the
patient's
chest there may also be rib fractures
preventing normal chest
Excursion and a flail
segment is is where two or more ribs are
broken in two or more places meaning
that part of the chest wall is
disconnected from the rest of the chess
wall meaning it doesn't move with the
rest of the chess wall and I've actually
seen this where you get the proper
paradoxical movement when the chest wall
moves up and out but the fla segment is
sucked in the way clearly compromising
ventilation and if someone's got a flail
segment that means there's been
significant trauma impacted onto the
surface of their chest and underneath
the flow segment there's a good chance
there's going to be pulmonary contusion
bruising of the lung also reducing the
efficiency of the breathing
process and hemothorax is also a
possibility where blood enters the
plural cavity and of course you can get
a hemothorax with a pneumothorax a hemon
numo thorax the two can get go
together so they're the sort of injuries
we're looking
for here's a fairly good saying all
injured patient should be given high
concentrations of oxygen so any
significantly traumatized patient should
be put on oxygen because we want to
maintain Optimum saturations in any
blood that is circul circulating around
the body to make sure the tissues of the
body are getting as much oxygen as the
breathing and circulatory system will
facilitate at that period of
time if there's still problems with the
airway we can consider a surgical
Airway perhaps uh below the thyroid
cartilage above the CID cartilage in the
C through the cryo thyroid ligament to
make to get an emergency surgical
Airway if there's a tension num thorax
present that should be identified and
decompressed as an emergency life saving
measure this will probably use involve
using a wide B canul in the
midclavicular line putting it in about
the third intercostal space to
decompress the num
thorax and of course always feel free it
never does any harm to use pulse
oximetry to help us to monitor the blood
oxygen levels quickly the only catch
with pulse oximetry is the current
generation of pulse oximeters cannot
differentiate between ox
hemoglobin and
carboxyhemoglobin so if someone's been
in a fire and might have inhaled carbon
monoxide this can give spuriously High
readings apart from that pulse ox
symmetry it is a useful clinical
indicator so a for Airway with survival
spine protection B for breathing with
ventilation C for circulation and
hemorrhage control our next priority and
the first thing to say is completely
obvious fix the leak stop the blood
coming out that's called definitive
Hemorrhage control so you might need to
apply direct pressure you might need to
put artery clips and legate bleeding
vessels you may need emergency
preoperative care so the patient can
have a splenectomy if the spleen is
bleeding whatever it is though you've
got to stop the leak definitive
hemorrage control means we get the
bleeding
stopped so we fix the leak and then we
need to put back some fluids so we give
intravenous replacement of intravascular
volume we need to restore the
intravascular
volume bear in mind that bleeding can be
onto the floor and four more places so
there's a bit of looking to do sometimes
to try and work out where the bleeding
is coming
from and we want to assess
blood volume and cardiac output so how
are we going to do
that well the patient if it's bad may
already be becoming
hypotensive and in trauma assume
hypotension is caused by hypovolemia
until proved otherwise now having said
that hypotension can have other causes
such as cardiac tanard or tension P
thorax that aren't necessarily
Hemorrhage Rel related but most cases of
hypertension are caused by
hypovolemia especially if the patient is
cold and peripherally shut down almost
certainly
hypovolemia level of Consciousness may
or may not be reduced in hypovolemia so
is not necessarily a definitive
indicator of blood loss so it may or may
not be reduced in hypovolemic
patients but the skin color will usually
be pale an ashen grayy color and white
and cold extremities now I know this is
harder if you're working with patients
that are black or brown as opposed to
working with people that are white so
look particularly at the lips the
conjunc I of the eye the fingernails the
palms of the hands the soles of the feet
look where you can the profusion of the
lips is a good indicator what color are
the patient's lips of the gone pale in
which case the patient is probably hypop
profused and they'll also be cold the
skin will be cold regardless of what
color the skin is the skin will be cold
because of peripheral shutdown they will
feel cold and because of the sympathetic
stimulation they can also be sweating so
they may well be cold and
clamming the pulse of course is a very
good
indicator peripheral and Central pulses
as we've talked about best to
take central pulses in badly traumatized
patients of course we can feel for
peripheral pulses and we're looking at
the rate the Rhythm and the volume and
the classical pulse in someone who is
hypovolemic through Hemorrhage is fast
weak and
thread it will be fast because they're
Tachi cardic it will be weak because the
volumes of blood are low and instead of
feeling like a nice
thick string or rope under your finger
it's very thin and thready the pulse
feels thready because the individual
stroke volumes are going to be low so
the volume of blood going through the
arterial system per cardiac pulsation or
per cardiac contraction will be reduced
fast weak
threading but check for central pulses
because when the blood pressure is low
the peripheral pulses may go
of course we need to get intravenous
catheters into these
patients large bore ones and short ones
so fluid will go quickly through a short
catheter and a wide catheter and we need
at least two of these probably one in
each arm so that we can get large
amounts of intravenous fluids into our
patients if that becomes
appropriate and initial fluid
resuscitation is now crystalloid
fluids this is fluids like saline normal
saline dextr saline or harman's or
ringers lactate type
Solutions crystalloids don't have the
big molecules like colloids and these
replace the fluid in all of the body
quickly and effectively and of course we
always want to titrate with the response
to see what sort of blood pressure we're
getting when we put some fluids in but
the three for one rule probably is going
to apply in most trauma
situations this means we give three Ms
of crystalloid fluid for every Mill of
blood that has been lost so if the
patient has lost a liter of blood one
liter of blood they're probably going to
need three lers of crystalloid fluid
resuscitation it's probably more than
you might think but this is what has
been found in Trauma Centers around the
world three for
one and the rhyme here is for every big
bleed 341 you will need three lers of
crystalloid fluid for every one liter of
blood
lost and obviously if we're running a
lot of cold fluids into the patient the
body temperature can drop so the
intravenous infusion should be warmed to
roundabout body temperature or just
above body
temperature now I'm not recommending a
microwave it would only be for emergency
situations ideally we have a water bath
at 38 or 39° Centigrade where we warm
the water up in failing that in
emergency situation we could put the
bags of harmans or saline in warm water
in a sink to warm them up to those sort
of
temperatures so all infusion should be
warmed a microwave is used in the
emergencies but never put blood in the
microwave you the red cells will just
explode if you do
that now consider other causes of
hypotension of course if patients are
not responding to fluids so if we're
giving adequate volumes or what we would
normally consider adequate volumes of
fluid replacement but the patient's
blood pressure is still low we describe
those as nonresponders and then we have
to look for other causes of the
hypotension which may include tension
num thorax or cardiac tanard or card or
or blunt chest trauma which has damaged
the heart in some way ECG of course is
always useful completely noninvasive
completely
safe and we can consider urinary
catheters unless there's a urethal
injury present so make sure there's no
reasons not to put a urinary catheter in
make sure there's no
contraindications but if there are the
hourly urine volume that we get from
urinary catheters are very helpful to
help us to titrate intravenous
fluids so in trauma we still do like to
use urinary catheters they're very
useful whereas in renal failure it's now
strongly discouraged but in this
situation we can titrate fluid
Replacements with hourly volumes of
urine and of course we're looking for a
minimum of 0.5 Ms of urine per hour per
kilogram of patient body mass in an
adult more urine than that in a child
and a child we're looking for maybe one
mil per hour per kilogram and in a
younger child we're looking for even
more 2 Ms per hour per
kilogram D for
disability a b c d disability looking at
neurological
status so obviously we want to assess
the patient level of
Consciousness we can use a alert to
voice alert or alert to Voice or alert
to pay or unresponsive an avpu scale but
GCS is better glasgo Coma Scale is
better but assess the patient's level of
Consciousness then the pupillary size
and reaction because this will tell us
if there's compression of the ocular
motor nerve indicating intracranial
pathology
first the pupil will become sluggish
then eventually it will become
unreactive and dilated and the dilated
puple occurs on the same side on the
same side as the pathology so if there's
a left hematoma developing it will be
the left pupil which starts to dilate
first it's on the same
side lateralizing signs is there any
weakness in the arms or the legs on one
side of the body that's not present on
the other side of the body that may
indicate again growing intracranial
pathology but this time it will be on
the opposite side so if it's the right
side of the body that's weak the
hematoma will be on the left hand side
of the brain whereas with the pupils
it's on the same side with the body it's
on the opposite side then we need to
assess any spinal cord
injury and the level of that spinal cord
pathology is it in the cervical spine
the thoracic spine the lumber spine
where is
it and beware patients may talk and
die now what this means is that the
patient might be talking to you but then
they may go on to
deteriorate this can particularly happen
in A&E departments with extra Dural
hematomas because they're usually caused
by arterial bleeds so the patient may be
talking
but the bleeding goes on then the inter
cranial pressure starts to go up and the
patient may go on and Cone as a result
of complication of tentorial
herniation so this reinforces the point
we made at the start continually
reassess your patients a b c and d as
you go along because some patients talk
when they come into the department but
may go on to die as a complication of
secondary brain
injury if the GCS is low that should be
a capital S if the GCS is
low then check the obvious things make
sure the patient being
oxygenated make sure they're being
ventilated and make sure they're being
profused because very often low GCS is
caused by pure poor brain
oxygenation poor ventilation of the
lungs poor profusion of the brain not by
any inter cranial pathology itself so
always check those basic things and
correct them if the glasgo Coma Scale is
low so e for
exposure
environment and everything
else so usually we'll cut off the
patients clothes because we don't know
what injuries are beneath them and move
their limbs or their body could cause
further injury if there's unstable
fractures for
example but we want to control the
environment to prevent
hypothermia because the hypothermia will
inhibit blood
coagulation that's why we warm
intravenous infusions and why we warm
blood before giving
it obvious wounds can be protected at
this stage with a dressing maybe just a
moist dressing to keep a wound moist
soaked with sterile saline or maybe even
inadine if we think infection is going
to be a
problem consider any other medical
problems epilepsy
hypoglycemia other things which may
complicate the patient
management and we want to relieve pain
as soon as possible without
drugs this could be done for example by
the position of the patient it could be
done by putting traction on a fracture
it could be done by immobilizing
fractures with splints to try and
relieve the pain without
medication but then as soon as the
diagnosis is made as the soon as the
patient's been properly assessed then we
want to treat with analgesics as soon as
a definitive diagnosis is made and then
we might want to give the patient some
quite sign ific
analgesics so one A&E preparation that
we sometimes give or group of
preparations is we can give ipren which
is a nonsteroidal anti-inflammatory drug
and
paracetamol and we can give Codine
phosphate as
well alternatively we might titrate in
10 mgrs of intravenous morphine with an
appropriate antiemetic but if we give
analgesics at two early stage that may
interfere with the diagnosis and
assessment so think about ways of
relieving pain straight away without
drugs and then as soon as senior medical
staff are happy treat with analgesics to
try and make the patient as painfree as
possible so we've talked about Airway
and cervical spine protection breathing
and
ventilation circulation and hemorr
control disability with the neurological
examination with avpu
GCS examination of the spinal cord and
peripheral nervous system and E for
exposure environment and everything else
and the last thing I just want to
mention is a few possible uh
pitfalls and one is the
elderly now the elderly may have a
limited ability to increase heart rate
in response to
Hemorrhage this this means that older
patients may not have the Tachi cardic
response that younger people will have
in other words an older person might
have lost blood but not be tachic cardic
because they are incapable of
compensating elderly people may be on
anti-coagulants even aspirin can prolong
bleeding time making hemorage more
significant and elderly patients may be
on medications for other medical
conditions
for example beta blockers might cause
low heart rates and for all these
reasons severely traumatized elderly
patients do not do as well as
traumatized younger
patients now it's important to mention
in children that they are absolutely
brilliant
compensators children can lose a lot of
blood but still maintain their blood
pressure for a long period of time they
can compensate exquisitely well but then
children decompensate very quickly and
can crash out very quickly so
deterioration can be precipitous and
catastrophic so we need good
observations of children's heart rates
we need to estimate their blood loss we
need to estimate their vasom motor
constriction as they
compensate because their blood pressure
will be maintained for a long time but
then drop off
quickly and the same is true of athletic
fit young people they can be very good
compensators and decompensate quickly
and also they can have lower normal
parameters than normal so a young fit
person might have a normal pulse rate of
50 so if they have a tacki cardio of 101
or 102 for them that might be a very
significant tacky
cardan so always think about your
observations in relation to to the
patient's normal conditions not in
relation to some sort of hypothetical
average that you might have in your
head and we have to constantly
re-evaluate all
patients so remember a b c d e is not a
one-off assessment we need to constantly
re-evaluate it because the condition of
patients can change once they are in our
care