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Clinical Hub,References,Level I Adult Trauma Center Manual,Practice Guidelines

Resuscitation of Multiple Injured Patient

Resuscitation of Multiple Injured Patient - Clinical Hub, References, Level I Adult Trauma Center Manual, Practice Guidelines

Focus

Objective

The following protocol outlines the priorities for managing the seriously injured patient according to the ATLS guidelines. This is a framework for the ongoing resuscitation, although it must be recognized that deviations will be necessary according to the patient’s status and ongoing re-evaluation

Defintions

  1. Multiple or serious injuries: patients who are defined as having injuries consistent with the severity guidelines that would classify them as a level 1 or level 2 trauma.
  2. Advanced trauma life support guidelines: Trauma prioritization guidelines developed by the Committee of Trauma of the American College of Surgeons, which are nationally recognized as the standards for trauma care.

Guidelines

The protocol below lists the priorities in the primary survey, resuscitation, and secondary survey phases of trauma management as adapted from ATLS.

  1. Life support (in order of priority)
    1. Airway: guarantee patency and assure that the patient can protect his/her airway
      1. Possible C-spine injury- maintain in-line stabilization (rigid collar and lateral immobilization)
        1. Suction secretions using Yankauer suction; remove foreign bodies; jaw thrust.
        2. Oral or nasopharyngeal airway if tolerated by patient
        3. If necessary, orotracheal intubation with in-line stabilization and rapid sequence intubation (RIS)
        4. Upper airway obstruction- cricothyrotomy
        5. 100% oxygen
      2. No neck injury, stridor or evident obstruction:
        1. Position the airway using jaw thrust
        2. Suction secretions
        3. Oral airway, if tolerated
        4. 100% oxygen
        5. Mask-assisted ventilation
        6. If no improvement, perform orotracheal intubation.
      3. No neck injury, no stridor but apparent upper airway obstruction:
        1. As in “ii” above
        2. If unsuccessful, cricothyrotomy
      4. Anterior neck injury, stridor and upper airway obstruction
          1. Suspect laryngeal crush injury or laryngotracheal separation
          2. Proceed to tracheostomy without prior attempt to endotracheal intubation.
      5. Head injury- intubate when GCS is less than or equal to 8
      6. Apneic – immediate orotracheal intubation with in-line stabilization or surgical cricothyrotomy
    2. Breathing
      1. Assess breath sounds bilaterally
      2. Mechanical ventilation if ventilator effort is inadequate
        1. Bag-Valve Mask initially
        2. Verify ETT position by end tidal CO2 determination
        3. Ventilator support with ventilator
      3. Tension pneumothorax:
        1. Immediate needle thoracostomy (14 or 16 guage IV catheter in second intercostal space) or tube thoracostomy.
        2. Tube thoracostomy to follow needle thoracostomy, if performed
        3. Chest x ray is contraindicated prior to treatment if patient has hemodynamic compromise.
      4. Hemothorax:
        1. Thoracostomy tube after fluid resuscitation.
        2. Plan for possible autotransfusion if applicable. v. Simple pneumothorax: Tube thoracostomy after confirmation by chest X-ray.
        3. Open pneumothorax:
          1. Cover defect with Vaseline dressing.
          2. Tube thoracostomy.
      5. Indications for thoracotomy (See Practice Guideline “Emergent Resuscitative Thoracotomy
        1. Immediate thoracotomy in the ED.
          1. Penetrating wound (except head) with no BP (but had signs of life at the scene < 10 minutes prior to arrival) or non-resuscitating BP (1200 ml initially or 800 ml total over next four hours.
          2. Urgent thoracotomy in the OR.
        2. Cardiac tamponade documented by ultrasound, pericardiocentesis, or pericardial window, or strong clinical findings.
        3. Widened mediastinum with left hemothorax or an aortogram confirming aortic transection (OR only).
        4. Hemothorax >1200 ml initially or 800 ml total over next four hours
        5. Ruptured esophagus
        6. Massive pleural air leak suggestive of ruptured bronchus after confirmation by bronchoscopy.
    3. Circulation
      1. Hemostasis – direct pressure to bleeding wounds.
      2. Treat shock
      3. Assess for etiology. Consider hypovolemic shock as most common cause.
      4. Neurogenic shock considered if evidence of spinal cord injury.
      5. If shock state is difficult to correct, consider source of bleeding that needs operative or angiographic intervention.
      6. Warm crystalloid solution, initially 2 liters LR), then packed cells (warmed to body temperature).
      7. Consider activating the Massive Transfusion Protocol if indicated by trauma surgeon.
      8. Head injury or lung injury – conservative, but maintain adequate fluid
      9. Resuscitation to keep BP and pulse in normal range. Strive to maintain normal hemodynamics and euvolemia.
      10. Cardiac tamponade: pericardiocentesis, needle or open (especially with anterior chest penetrating injury).
      11. Shock with reduced pulse pressure unresponsive to volume.
      12. Neck vein distention or elevated CVP greater than 20 cm of water pressure.
      13. Rule-out tension pneumothorax (this is more likely than tamponade in blunt trauma).
    4. Central nervous system
      1. Central nervous system (See Practice Guideline “Brain Injury”).
      2. Assess Glasgow Coma Scale (for GCS less than 8, intubate). Consider neurosurgery consult for:
        1. GCS <12.
        2. Focal deficit.
        3. Unequal pupils not explained by local injury or peripheral nerve palsy.
      3. Continue resuscitation to maintain euvolemia.
      4. Maintain oxygenation >95%.
      5. Ventilation to achieve pCO2 around 40 mmHg.
      6. Medications:
        1. Sedate with morphine/fentanyl and/or lorazepam/midazolam (or other agents) to avoid agitation and protect airway.
        2. consider 3% Saline 5cc/kg or mannitol 1 gm/kg to prevent herniation secondary to brain swelling if focal neurologic findings or positive CT scan for hemorrhage.
        3. For urgent seizure consider Lorazepam 1-2 mg IV (adults) or 0.1 mg/kg (children)
        4. Consider Phenytoin 18 – 20 mg/kg (est 1,000 mg for 55 kg pt) or Keppra 1000mg prophylaxis.
      7. CT scan of head, as indicated (see protocol for radiologic studies).
      8. Remove all clothing.
        1. Maintain normothermia.
        2. Warm blankets.
        3. Overhead heating lights.
        4. Warm IV fluids.
        5. Keep resuscitation room very warm.
        6. Baer Hugger
      9. Insert nasogastric/orogastric tube and Foley catheter, as indicated, and after rectal exam.
  2. Conduct secondary survey (head-to-toe physical examination):
    1. Maxillofacial: Control bleeding from scalp and face (with skin staples, suture ligatures, packing, and/or definitive wound closure).
    2. Neck:
      1. Palpate for fractures and instability.
      2. Examine for external injuries
      3. If there is significant bruising or abrasion of side of neck, consider carotid evaluation (CT angio, or duplex)
    3. Chest:
      1. Re-evaluate breath sounds and ventilator adequacy
      2. Examine for external injuries
    4. Abdomen:
      1. Quick physical assessment (distention, seatbelt injury, contusions, tenderness).
      2. Perform ultrasound FAST exam on all patients with indications of possible abdominal injury.
      3. Determine need for further evaluation (if unstable, do DPL or perform laparotomy if FAST shows hemoperitoneum; if stable, do abdominal CT scan)
      4. Abdominal hemorrhage – distention or unexplained hypotension (indicated with US FAST or positive DPL) Immediate laparotomy in OR
    5. If unstable pelvis, avoid unnecessary movement to minimize bleeding. Consider angiographic embolization or external fixator for associated vascular injury. Stabilize pelvis.
    6. Fractures stabilizations
      1. Reduce fracture dislocation
      2. Apply traction splint for femur fracture
      3. Evaluate neurovascular compromise
      4. Stop bleeding -apply tight compressive dressings. Direct pressure on arterial bleeding.
      5. Antibiotics for open fractures
    7. Spine
      1. Assess for sensory and motor deficits
      2. Roll patient in in line cervical stabilization
    8. Coordinate radiologic examination
      1. Chest X-Ray
      2. AP pelvis
  3. After stabilization
    1. Triage- ongoing
      1. Prioritize injuries:
        1. Life threatening
        2. Stable but potentially life threatening
        3. Limb threatening
        4. No-life or Limb threatening
      2. Determine sequence: X-ray, OR, ICU, general care, IMC
      3. Consult services should be called
    2. Establish contact with family if possible
    3. History
    4. Determine need for tetanus and antibiotic coverage
    5. Determine need for admission. Arrange for bed in appropriate unit
  4. Continued reassessment is mandatory
    1. Vital signs: frequent determinations of vital signs as determined by the severity of Injury, should be made. It is always better to check too frequently than to be left in the dark.
    2. Outputs: should be checked frequently during the resuscitation phase and then hourly. When stable – urine, chest tube, nasogastric.
    3. Be sensitive to trends in physical examination and vital signs - ask yourself, “Has the patient’s response to fluid infusion and early stabilization been appropriate?”

OBJECTIVE: The following protocol outlines the priorities for managing the seriously injured patient according to the ATLS guidelines. This is a framework for the ongoing resuscitation, although it must be recognized that deviations will be necessary according to the patient’s status and ongoing re-evaluation

DEFINITIONS:

  1.  Multiple or serious injuries: patients who are defined as having injuries consistent with the severity guidelines that would classify them as a level 1 or level 2 trauma.
  2. Advanced trauma life support guidelines: Trauma prioritization guidelines developed by the Committee of Trauma of the American College of Surgeons, which are nationally recognized as the standards for trauma care.

GUIDELINES:
The protocol below lists the priorities in the primary survey, resuscitation, and secondary survey phases of trauma management as adapted from ATLS.

  1. Life support (in order of priority)
    1. Airway: guarantee patency and assure that the patient can protect his/her airway

                                                               i.      Possible C-spine injury- maintain in-line stabilization (rigid collar and lateral immobilization)

1.       Suction secretions using Yankauer suction; remove foreign bodies; jaw thrust.

2.       Oral or nasopharyngeal airway if tolerated by patient

3.       If necessary, orotracheal intubation with in-line stabilization and rapid sequence intubation (RIS)

4.       Upper airway obstruction- cricothyrotomy

5.       100% oxygen

                                                             ii.      No neck injury, stridor or evident obstruction:

1.       Position the airway using jaw thrust

2.       Suction secretions

3.       Oral airway, if tolerated

4.       100% oxygen

5.       Mask-assisted ventilation

6.       If no improvement, perform orotracheal intubation.

                                                            iii.      No neck injury, no stridor but apparent upper airway obstruction:

1.       As in “ii” above

2.       If unsuccessful, cricothyrotomy

                                                           iv.      Anterior neck injury, stridor and upper airway obstruction

1.       Suspect laryngeal crush injury or laryngotracheal separation

2.       Proceed to tracheostomy without prior attempt to endotracheal intubation.

                                                             v.      Head injury- intubate when GCS is less than or equal to 8

                                                           vi.      Apneic – immediate orotracheal intubation with in-line stabilization or surgical cricothyrotomy

    1. Breathing

                                                               i.      Assess breath sounds bilaterally

                                                             ii.      Mechanical ventilation if ventilator effort is inadequate

1.       Bag-Valve Mask initially

2.       Verify ETT position by end tidal CO2 determination

3.       Ventilator support with ventilator

                                                            iii.      Tension pneumothorax:

1.       Immediate needle thoracostomy (14 or 16 guage IV catheter in second intercostal space) or tube thoracostomy.

2.       Tube thoracostomy to follow needle thoracostomy, if performed

3.       Chest x ray is contraindicated prior to treatment if patient has hemodynamic compromise.

                                                           iv.       Hemothorax:

1.       Thoracostomy tube after fluid resuscitation.

2.       Plan for possible autotransfusion if applicable. v. Simple pneumothorax: Tube thoracostomy after confirmation by chest X-ray.

3.       Open pneumothorax:

a.       Cover defect with Vaseline dressing.

b.      Tube thoracostomy.

                                                             v.      Indications for thoracotomy (See Practice Guideline “Emergent Resuscitative Thoracotomy

1.       Immediate thoracotomy in the ED.

a.       Penetrating wound (except head) with no BP (but had signs of life at the scene < 10 minutes prior to arrival) or non-resuscitating BP (1200 ml initially or 800 ml total over next four hours.

b.       Urgent thoracotomy in the OR.

2.       Cardiac tamponade documented by ultrasound, pericardiocentesis, or               pericardial window, or strong clinical findings.

3.        Widened mediastinum with left hemothorax or an aortogram confirming aortic transection (OR only).

4.       Hemothorax >1200 ml initially or 800 ml total over next four hours

5.       Ruptured esophagus

6.       Massive pleural air leak suggestive of ruptured bronchus after confirmation by bronchoscopy.

 

    1. Circulation

i.              Hemostasis – direct pressure to bleeding wounds.

ii.             Treat shock

iii.            Assess for etiology. Consider hypovolemic shock as most common cause.

iv.           Neurogenic shock considered if evidence of spinal cord injury.

v.            If shock state is difficult to correct, consider source of bleeding that needs operative or angiographic intervention.

vi.           Warm crystalloid solution, initially 2 liters LR), then packed cells (warmed to

body temperature).

vii.          Consider activating the Massive Transfusion Protocol if indicated by trauma

surgeon.

viii.         Head injury or lung injury – conservative, but maintain adequate fluid

Resuscitation to keep BP and pulse in normal range. Strive to maintain normal

hemodynamics and euvolemia.

ix.           Cardiac tamponade: pericardiocentesis, needle or open (especially with

anterior chest penetrating injury).

x.            Shock with reduced pulse pressure unresponsive to volume.

xi.           Neck vein distention or elevated CVP greater than 20 cm of water

xii.          pressure.

xiii.         Rule-out tension pneumothorax (this is more likely than tamponade in

blunt trauma).

    1. Central nervous system

                                                               i.      Central nervous system (See Practice Guideline “Brain Injury”).

                                                             ii.       Assess Glasgow Coma Scale (for GCS less than 8, intubate). Consider

neurosurgery consult for:

1.        GCS <12.

2.       Focal deficit.

3.       Unequal pupils not explained by local injury or peripheral nerve palsy.

                                                            iii.       Continue resuscitation to maintain euvolemia.

                                                           iv.      Maintain oxygenation >95%.

                                                             v.       Ventilation to achieve pCO2 around 40 mmHg.

                                                           vi.       Medications:

1.        Sedate with morphine/fentanyl and/or lorazepam/midazolam (or other agents)

to avoid agitation and protect airway.

2.        consider 3% Saline 5cc/kg or mannitol 1 gm/kg to prevent herniation

               secondary to brain swelling if focal neurologic findings or positive CT  scan for hemorrhage.

3.       For urgent seizure consider Lorazepam 1-2 mg IV

              (adults) or 0.1 mg/kg (children)

4.       Consider Phenytoin 18 – 20 mg/kg (est 1,000 mg for 55 kg pt) or Keppra

               1000mg prophylaxis.

                                                          vii.       CT scan of head, as indicated (see protocol for radiologic studies).

                                                        viii.       Remove all clothing.

 Maintain normothermia.

 Warm blankets.

Overhead heating lights.

 Warm IV fluids.

 Keep resuscitation room very warm.

 Baer Hugger

                                                           ix.      Insert nasogastric/orogastric tube and Foley catheter, as indicated, and after rectal exam.

  1. Conduct secondary survey (head-to-toe physical examination):
    1. Maxillofacial: Control bleeding from scalp and face (with skin staples, suture ligatures, packing, and/or definitive wound closure).
    2. Neck:   

                                                               i.      Palpate for fractures and instability.

                                                             ii.      Examine for external injuries

                                                            iii.      If there is significant bruising or abrasion of side of neck, consider carotid evaluation (CT angio, or duplex)

    1. Chest:

                                                               i.      Re-evaluate breath sounds and ventilator adequacy

                                                             ii.      Examine for external injuries

    1. Abdomen:

                                                               i.      Quick physical assessment (distention, seatbelt injury, contusions, tenderness).

                                                             ii.      Perform ultrasound FAST exam on all patients with indications of possible abdominal injury.

                                                            iii.      Determine need for further evaluation (if unstable, do DPL or perform laparotomy if FAST shows hemoperitoneum; if stable, do abdominal CT scan)

                                                           iv.      Abdominal hemorrhage – distention or unexplained hypotension (indicated with US FAST or positive DPL) Immediate laparotomy in OR

    1. If unstable pelvis, avoid unnecessary movement to minimize bleeding. Consider angiographic embolization or external fixator for associated vascular injury. Stabilize pelvis.
    2. Fractures stabilizations

                                                               i.      Reduce fracture dislocation

                                                             ii.      Apply traction splint for femur fracture

                                                            iii.      Evaluate neurovascular compromise

                                                           iv.      Stop bleeding -apply tight compressive dressings. Direct pressure on arterial bleeding.

                                                             v.      Antibiotics for open fractures

    1. Spine

                                                               i.      Assess for sensory and motor deficits

                                                             ii.      Roll patient in in line cervical stabilization

    1. Coordinate radiologic examination

                                                               i.      Chest X-Ray

                                                             ii.      AP pelvis

  1. After stabilization
    1. Triage- ongoing

                                                               i.      Prioritize injuries:

1.       Life threatening

2.       Stable but potentially life threatening

3.       Limb threatening

4.       No-life or Limb threatening

                                                             ii.      Determine sequence:  X-ray, OR, ICU, general care, IMC

                                                            iii.      Consult services should be called

    1. Establish contact with family if possible
    2. History
    3. Determine need for tetanus and antibiotic coverage
    4. Determine need for admission. Arrange for bed in appropriate unit
  1. Continued reassessment is mandatory
    1. Vital signs: frequent determinations of vital signs as determined by the severity of

Injury, should be made. It is always better to check too frequently than to be left in the

Dark.

    1. Outputs: should be checked frequently during the resuscitation phase and then hourly

When stable – urine, chest tube, nasogastric.

    1. Be sensitive to trends in physical examination and vital signs - ask yourself, “Has the

Patient’s response to fluid infusion and early stabilization been appropriate?”