10 Care of the Acutely Injured
PRIMARY SURVEY
It is a rapid and systematic evaluation to detect and manage life-threatening injuries (Box 10.4). A trauma team should be there to manage airway, breathing and circulation problems simultaneously.
Box 10.4: Primary survey A–Airway and total spine control B–Breathing and ventilatory support C–Circulation with hemorrhage control D–Disability (brief neurological evaluation) E–Exposure (completely undress the patient)
A. Airway
• The first priority in a critically injured patient is to establish and maintain a patent airway. It helps in delivering sufficient oxygen to tissues and avoids hypoxemic organ damage.
• Management of airway should always be combined with control of cervical spine (with hands/lateral blocks/hard cervical collar).
• Ask the patient his name. If he can answer, his airway is intact and he has adequate cerebral perfusion.
• Initial assessment of airway is done by: Look, Listen and Feel (Box 10.5).
Figs 10.1A and B: Log rolling the patient
Box 10.5: Airway assessment
Look Cyanosis
Chest movements Respiratory rate
Trauma (Maxillofacial, chin, mouth, neck, chest)
Listen Voice quality
Breath sounds
Abnormal sounds (crepts, rhonchi) Feel (with hands) Chest movements
Subcutaneous emphysema Tracheal position
Broken teeth/ foreign bodies in oral cavity
Tongue fall
• In case of acute airway obstruction, management is done as follows (Box 10.6):
High flow oxygen is administered by face mask.
Head tilt: Flexing the cervical spine and then extending the head backwards improves airway patency.
Chin lift combined with opening the mouth clears the tongue fall.
Jaw thrust: The mandible and tongue are displaced anteriorly by pushing forwards the angle of the mandible. However, it can cause significant movement of an unstable cervical spine.
Oropharyngeal or nasopharyngeal airway (Fig. 10.2) can be used to improve a partially obstructed airway. However, a nasal airway is inappropriate in suspected fracture base of skull.
• If patient still has labored breathing or no breathing (apneic), it is an indication for urgent endotracheal intubation. Other indications for tracheal intubation are given in Box 10.7.
Box 10.7: Indications for endotracheal intubation Immediate: Apnea
Urgent: Inadequate breathing after jaw thrust and airway insertion
Depressed level of consciousness (GCS<8) Risk of aspiration pneumonia (from vomitus, blood)
• As an alternative to endotracheal intubation, laryngeal mask airway (LMA) (Fig. 10.3) can be used for ventilation.
• If endotracheal intubation fails, surgical cricothyroi-dotomy or tracheostomy may be performed under local anesthesia.
Fig. 10.2: (A) Face mask, (B) oropharyngeal and (C) nasopharyngeal airway
Box 10.6: Management of airway
Patient can talk High flow oxygen, control cervical spine
Patient unconscious, Oral suction, chin lift, head tilt, Try noisy breathing oropharyngeal/ nasopharyngeal
airway
Unable to obtain clear Endotracheal intubation airway (maxillofacial
injury, bleeding, vomiting, burns)
Failed intubation Cricothyroidotomy/Tracheostomy
Fig. 10.3: (A) Laryngeal mask airway and (B) cuffed endotracheal tube
a. Surgical cricothyroidotomy: It is a life saving proce-dure and must be done quickly as hypoxic brain injury occurs within 3-5 minutes of no oxygenation.
Surgical anatomy: The cricothyroid membrane is an avascular fibroelastic membrane between thyroid cartilage (above) and cricoid cartilage (below). The laryngeal prominence or “Adam’s apple” is the most important landmark. Identify the cricothyroid membrane by feeling a notch inferior to laryngeal prominence.
Equipments:
Size 10 scalpel blade.
Size 6-7 tracheostomy tube.
Tracheal spreader or artery forceps.
Procedure:
• Patient is placed in supine position.
• Locate cricothyroid membrane by palpating Adam’s apple and moving downwards.
• Give local anesthesia (if there is time and patient is conscious).
• Stabilize the thyroid cartilage with left hand. Make a horizontal stab incision in midline through skin and cricothyroid membrane allowing only tip of the scalpel blade to enter trachea. Enlarge the opening using artery forceps or tracheal spreader (Figs 10.4A to C).
Insert a cuffed tube into the hole directing the tube distally into the trachea and inflate the cuff. Attach a connector to the tube and ventilate the patient.
b. Needle cricothyroidotomy: It can be done as an emergency life saving measure when equipment for cricothyroidotomy is not available. A large bore (12-14 G) cannula is introduced through the skin and
cricothyroid membrane in downward direction to enter the trachea. High flow oxygen is given through the cannula. Arrange for a definitive airway as needle cricothyroidotomy is only suitable as a temporary measure (10-15 minutes).
c. Tracheostomy: (See Chapter 16: Diseases of Larynx).
• In fractures of facial skeleton, edema develops within 60-90 minutes. Thus, immediately after injury to facial skeleton, airway might appear to be adequate.
But it gets occluded rapidly by swelling of the tongue, facial and pharyngeal tissues causing acute respiratory obstruction. Hence, oropharyngeal airway should be inserted during initial period (golden hour) even if airway appears to be unobs-tructed. If it is not done, an emergency tracheostomy may be required later with risk of hypoxic damage.
• Massive nasopharyngeal bleeding causing airway obstruction: In case of severe facial hemorrhage following trauma, it can prove fatal without early recognition and definitive first aid. The patient presents with bleeding from nose and mouth that is staining cloths, bed, on the attendants and on the floor. Attempt to CT scan these patients without control of bleeding may result in death by exsangui-nation. The correct steps in management are:
Secure the airway by cricothyroidotomy/
tracheostomy and ventilate.
Pass two 22F Foley’s catheters through two nostrils and hook by index finger into the mouth.
A roll gauze pack is secured through eye of each catheter with 0 nylon stitch and wedged in
post-Figs 10.4A to C: Surgical cricothyroidotomy
nasal space using digital pressure and traction on catheters.
The Foley’s catheters are tied over a bolster to give constant traction.
Further anterior nasal packing and/or balloon inflation may be required to control nasal bleeding.
Ongoing oral bleeding can be controlled by packing of oropharynx and oral cavity.
The pack may be left for 48-72 hrs, if required.
Prolonged pressure from pack may cause necrosis of soft palate.
In some uncontrolled cases, bilateral external carotid artery ligation may be required.
If facilities are available, angiographic emboli-zation of maxillary artery branches can stop bleeding.
Definitive maxillofacial surgery is undertaken after control of acute hemorrhage.
B. Breathing and Ventilatory Support
Once a clear airway has been obtained, the patient’s breathing is assessed. The chest is exposed and rate and depth of respiration are measured. A respiratory rate of
<10 or >30/min indicates a severe underlying problem.
There are five life-threatening chest injuries that must be identified and treated during primary survey.
i. Tension pneumothorax: Air enters the pleural cavity from bronchial injury. But air is unable to go back due to a valve mechanism leading to rapidly increasing pneumothorax. It can kill the patient within minutes. Clinical features are:
• Respiratory distress “ I can’t breathe”.
• Hyperinflated chest (resonant on percussion).
• Deviated trachea.
• Decreased breath sounds.
• Tachycardia.
• Hypotension.
Needle thoracocentesis should be done immediately by putting 12G cannula in pleural cavity through 2nd intercostal space in midclavi-cular line. It should be followed by definitive chest tube placement that is connected to underwater seal drain.
ii. Massive hemothorax: It is collection of more than 1500 ml blood into the pleural cavity. The patient
may present in shock. Signs are similar to tension pneumothorax except for dullness on percussion.
Treatment is intercostal tube drainage.
iii. Sucking chest wound: It should be covered using dressing taped on three sides, allowing escape of air through a valve like action.
iv. Flail chest: Two or more ribs are broken at two points leading to “paradoxical respiration”. The flail segment moves in during inspiration and moves out during expiration (Fig. 10.5). There is underlying lung contusion and hypoxia. Patient may require tracheal intubation and positive pressure ventilation. There may be subcutaneous emphysema (surgical emphysema) due to lung injury requiring intercostal intubation (Fig. 10.6).
Fig. 10.5: Flail chest
Fig. 10.6: Massive surgical emphysema following flail chest
v. Pericardial tamponade: There is collection of blood in the pericardial cavity due to injury to the underlying heart. The patient usually does not reach hospital alive. The clinical signs are: Hypotension, muffled heart sounds and distended neck veins (Beck’s triad). Needle pericardiocentesis should be performed and urgent thoracotomy arranged.
C. Circulation and Hemorrhage Control
• The best early signs of shock are pallor, cool clammy skin, tachycardia, anxiety and tachypnea.
• Hypotension is a late sign when >30% of blood volume is lost.
• Control external bleeding with direct pressure.
• Splint limb fractures.
• Insert two large bore cannulae (16 G in adults) in veins of ante-cubital fossa or forearm.
• If venous access not obtained, do cut-down on long saphenous vein at the ankle or median basilic vein in the arm.
• In children up to 10 years of age, intraosseous needle infusion is preferable to central venous access.
• Take blood samples for grouping and cross matching.
• Restore blood volume by rapid infusion of Ringer lactate solution (2 liters).
• Blood replacement by group specific cross matched blood or O-negative blood.
• If shock persists despite resuscitation, exclude non-hypovolemic causes of shock, e.g. cardiogenic shock, neurogenic shock.
• If investigations (chest X-ray, abdominal ultrasound, X-ray pelvis) suggest uncontrolled internal bleeding, consider exploration.
• Do constant monitoring of the patient with cardiac monitor, pulse oximeter, urine output measurement.
• The most important errors contributing to avoidable deaths are—failure to control bleeding and delay in operation.
• Outlines of hemorrhage control are given in Box 10.8.
Box 10.8: Management of circulation
Assess: Consciousness level, skin color, temperature, pulse, BP.
Access: Two peripheral intravenous lines.
Arrest: External hemorrhage.
Ask: Does patient require emergency surgery?
(Thoracotomy/ Laparotomy/ Fracture fixation).
Attach: Cardiac monitor, pulse oximeter, urinary catheter, Ryle’s tube (if indicated).
D. Disability
A rapid neurological assessment is done at the end of primary survey to determine:
• Level of consciousness (Box 10.9).
• Pupillary size and reaction to light.
• Limb movement.
Box 10.9: ‘AVPU’ method of assessing level of consciousness A Alert
V Responds to vocal stimuli P Responds to painful stimuli U Unresponsive
In case of unilateral fixed dilated pupil and neurological deficit, consult with a neurosurgeon immediately.
E. Exposure
• Completely expose the patient, usually by cutting off the clothes, so that complete examination can be performed.
• Log roll and examine the back.
• After completing the examination, cover the patient to prevent hypothermia.