Primary Trauma Care Manual
Primary Trauma CareAuthorsDouglasAWilkinsonandMarcus W Skinner
Primary Trauma CarePrimary Trauma Care ManualStandard Edition2000A Manual for Trauma Managementin District and Remote LocationsISBN 0-95-39411-0-8Published by Primary Trauma Care FoundationNorth House, Farmoor Court, Cumnor Road, Oxford OX2 9LUEmail: admin@primarytraumacare.orgTo be copied with permission from the publisher.
Primary Trauma CareContents Introduction .3 Trauma in Perspective .4 ABCDE of Trauma .5 Airway Management .7 Ventilation (Breathing) Management .8 Circulatory Management .9 Secondary Survey .12 Chest Trauma .14 Abdominal Trauma .17 Head Trauma .19 Spinal Trauma .21 Limb Trauma .23 Special Trauma Cases .25 Paediatrics.25 Pregnancy .27 Burns .28 Transportation of the Trauma Patient .29 AppendicesAppendix 1:Appendix 2:Appendix 3:Appendix 4:Appendix 5:Appendix 6:Appendix 7:Airway Management Techniques .30Paediatric Physiological Values .32Cardiovascular Parameters .33Glasgow Coma Scale .33Cardiac Life Support .34Trauma Response .35Activation Plan for Trauma Team .36
Primary Trauma CareIntroductionTrauma transcends all national boundaries. Many less affluent countries have asignificant proportion of road and industrial trauma in a generally youngpopulation. Morbidity and mortality associated with such trauma can be reducedby early and effective medical intervention.This Primary Trauma Care course is intended to provide basic knowledge and skillsnecessary to identify and treat those traumatised patients who require rapidassessment, resuscitation and stabilisation of their injuries. This course willparticularly highlight the need for early recognition and timely intervention inspecific life-threatening conditions.This course is intended to provide material by lectures and practical skill stationsthat represents an acceptable method of management for trauma. It provides avery basic foundation on which doctors and health workers can build the necessaryknowledge and skills for trauma management with minimal equipment and withoutsophisticated technological requirements.There are several very successful and well organised trauma courses and manualsavailable, including the American College of Surgeons ATLS course and the EMSTAustralian course. These courses are directed to medical personnel in well equippedhospitals with oxygen, communication and transport etc. and offer a comprehensivesyllabus. The Primary Trauma Care is not a substitute for these courses, but usessimilar basic principles and emphasises basic trauma care with minimal resources.The ObjectivesAt the completion of this course you should:1. Understand the priorities of trauma management2. Be able to rapidly and accurately assess trauma patients needs3. Be able to resuscitate and stabilise trauma patients4. Know how to organise basic trauma care in your hospital.
Primary Trauma CareTrauma in PerspectiveMost countries of the world are experiencing an epidemic of trauma, but the mostspectacular increase has been in the developing countries. Proliferation of roadsand use of vehicles has led to a rapid increase in injuries and deaths and manyperipheral medical facilities find themselves faced with multiple casualties frombus crashes or other disasters. Severe burns are also common in both urban andrural areas.A number of important differences between high and low-income countries makedevelopment of a specifically designed Primary Trauma Care Course beneficial.They include: the great distances over which casualties may have to be transported to reacha medical facility the time taken for patients to reach medical care the absence of high-tech equipment and supplies the absence of skilled people to operate and service it.PREVENTION of trauma is by far the cheapest and safest mode to manage trauma.This depends on the location’s resources and factors such as: culturemanpowerpoliticshealth budgettraining.Every effort should be made by the medical trauma teams to address the abovefactors in the prevention of trauma. Much of this lies beyond the scope of thismanual, but time will be spent on the course looking at local circumstances andprevention possibilities.
Primary Trauma CareABCDE of TraumaThe management of severe multiple injury requires clear recognition ofmanagement priorities and the goal is to determine in the initial assessment thoseinjuries that threaten the patient’s life. This first survey, the ‘primary’ survey, ifdone correctly should identify such life-threatening injuries such as: airway obstructionchest injuries with breathing difficultiessevere external or internal haemorrhageabdominal injuries.If there is more than one injured patient then treat patients in order of priority(Triage). This depends on experience and resources (Discussed in the practicalsessions).The ABCDE survey (Airway, Breathing, Circulation, Disability and Exposure) isundertaken. This primary survey must be performed in no more than 2–5 minutes.Simultaneous treatment of injuries can occur when more than one life-threateningstate exists. It includes: AirwayAssess the airway. Can patient talk and breathe freely? If obstructed, the steps to beconsidered are: chin lift/jaw thrust (tongue is attached to the jaw)suction (if available)guedel airway/nasopharyngeal airwayintubation. NB keep the neck immobilised in neutral position.BreathingBreathing is assessed as airway patency and breathing adequacy are re-checked. Ifinadequate, the steps to be considered are: decompression and drainage of tension pneumothorax/haemothoraxclosure of open chest injuryartificial ventilation.Give oxygen if available.Reassessment of ABC’s must be undertaken if patient is unstable
Primary Trauma Care CirculationAssess circulation, as oxygen supply, airway patency and breathing adequacy arere-checked. If inadequate, the steps to be considered are: stop external haemorrhage establish 2 large-bore IV lines (14 or 16 G) if possible administer fluid if available. DisabilityRapid neurological assessment (is patient awake, vocally responsive to pain orunconscious). There is no time to do the Glasgow Coma Scale so a awake verbal response painful response unresponsiveAVPUsystem at this stage is clear and quick. ExposureUndress patient and look for injury. If the patient is suspected of having a neck orspinal injury, in-line immobilization is important. This will be discussed in thepractical sessions.NOTES
Primary Trauma CareAirway ManagementThe first priority is establishment or maintenance of airway patency. Talk to the patientA patient who can speak clearly must have a clear airway. The unconscious patientmay require airway and ventilatory assistance. The cervical spine must be protectedduring endotracheal intubation if a head, neck or chest injury is suspected. Airwayobstruction is most commonly due to obstruction by the tongue in the unconsciouspatient. Give oxygen (if available, via self-inflating bag or mask) Assess airwayThe signs of airway obstruction may include: snoring or gurglingstridor or abnormal breath soundsagitation (hypoxia)using the accessory muscles of ventilation/paradoxical chest movementscyanosis.Be alert for foreign bodies. The techniques used to establish a patent airway areoutlined in Appendix1 and will be reviewed in the practical sessions. Intravenoussedation is absolutely contraindicated in this situation. Consider need for advanced airway managementIndications for advanced airway management techniques for securing the airwayinclude: persisting airway obstructionpenetrating neck trauma with haematoma (expanding)apnoeahypoxiasevere head injurychest traumamaxillofacial injury.Airway obstruction requires URGENT treatment
Primary Trauma CareVentilation (Breathing) ManagementThe second priority is the establishment of adequateventilation. Inspection (LOOK) of respiratory rate is essential. Are any ofthe following present cyanosispenetrating injurypresence of flail chestsucking chest woundsuse of accessory muscles?Palpation (FEEL) for tracheal shift broken ribs subcutaneous emphysema percussion is useful for diagnosis of haemothorax and pneumothorax.Auscultation (LISTEN) for pneumothorax (decreased breath sounds on site of injury) detection of abnormal sounds in the chest.Resuscitation actionThis is covered in lecture and in practical sessions: see Appendix 5 the chest pleura is drained of air and blood by insertion of an intercostaldrainage tube as a matter of priority and before chest X-ray if respiratory distressexists when indications for intubation exist but the trachea cannot be intubated,direct access via a cricothyroidotomy may be achieved. See Appendix 1.Special notes If available, maintain the patient on oxygen until complete stabilisation isachieved. If a tension pneumothorax is suspected then one large-bore needle should beintroduced into the pleural cavity through the second intercostal space, mid clavicular line to decompress the tension and allow time for the placement of anintercostal tube. If intubation in one or two attempts is not possible a cricothyroidotomyshould be considered priority. This depends on experienced medical personnelbeing available, with appropriate equipment, and may not be possible in manyplaces.DO NOT persist with intubation attempts without ventilating the patient
Primary Trauma CareCirculatory ManagementThe third priority is establishment of adequate circulation.‘Shock’ is defined as inadequate organ perfusion and tissue oxygenation. In thetrauma patient it is most often due to hypovolaemia.The diagnosis of shock is based on clinical findings: hypotension, tachycardia,tachypnoea, as well as hypothermia, pallor, cool extremities, decreased capillaryrefill, and decreased urine production. See Appendix 3.There are different types of shock including:Haemorrhagic (hypovolaemic) shock: Due to acute loss of blood or fluids. Theamount of blood loss after trauma is often poorly assessed and in blunt trauma isusually underestimated. Remember large volumes of blood may be hidden in the abdominal and pleural cavity femoral shaft fracture may lose up to 2 litres of blood pelvic fracture often lose in excess of 2 litres of blood.Cardiogenic shock: Due to inadequate heart function. This may be from myocardial contusion (bruising)cardiac tamponadetension pneumothorax (preventing blood returning to heart)penetrating wound of the heartmyocardial infarction.Assessment of the jugular venous pressure is essential in these circumstances andan ECG should be recorded if available.Neurogenic shock: Due to the loss of sympathetic tone, usually resulting from spinalcord injury, with the classical presentation of hypotension without reflextachycardia or skin vasoconstriction.Septic shock: Rare in the early phase of trauma but is a common cause of late death(via multi-organ failure) in the weeks following injury. It is most commonly seenin penetrating abdominal injury and burns patients.Hypovolaemia is a life-threatening emergencyand must be recognised and treated aggressively
Primary Trauma CareCirculatory Resuscitation Measures(See Appendix 5)The goal is to restore oxygen delivery to the tissues.As the usual problem is loss of blood, fluid resuscitation must be a priority. Adequate vascular access must be obtained. This requires the insertion of atleast two large-bore cannulas (14–16 G). Peripheral cut down may benecessary. Infusion fluids (crystalloids e.g. N/Saline as first line) should be warmed tobody temperature if possible (e.g. prewarm in bucket of warmed water).Remember hypothermia can lead to abnormal blood clotting. Avoid solutions containing glucose. Take any specimens you need for laboratory and cross matching.UrineMeasure urine output as an indicator of circulation reserve. Output should be morethan 0.5 ml/kg/hr. Unconscious patients may need a urinary catheter, if they arepersistently shocked.Blood transfusionThere may be considerable difficulty in getting blood. Remember possibleincompatibility, hepatitis B and HIV risks, even amongst patient’s own family.Blood transfusion must be considered when the patient has persistenthaemodynamic instability despite fluid (colloid/crystalloid) infusion. If the typespecific or cross-matched blood is not available, type O negative packed red bloodcells should be used. Transfusion should, however, be seriously considered if thehaemoglobin level is less than 7 g/dl and if the patient is still bleeding.First priority: stop bleeding Injuries to the limbs: Tourniquets do not work. Besides, tourniquets causereperfusion syndromes and add to the primary injury. The recommendedprocedure of “pressure dressing” is an ill-defined entity: Severe bleeding fromhigh-energy penetrating injuries and amputation wounds can be controlledby subfascial gauze pack placement plus manual compression on the proximalartery plus a carefully applied compressive dressing of the entire injured limb. Injuries to the chest: The most common source of bleeding is chest wallarteries. Immediate in-field placement of chest tube drain plus intermittentsuction plus efficient analgesia (IV ketamine is the drug of choice) expandLoss of blood is the main cause of shock in trauma patients
Primary Trauma Carethe lung and seal off the bleeding. Injuries to the abdomen: “Damage control laparotomy” should be done assoon as possible on cases where fluid resuscitation cannot maintain a systolicBP at 80–90 mm. The sole objective of DC laparotomy is to gauze pack thebleeding abdominal quadrants, whereafter the mid-line incision is temporarilyclosed within 30 minutes with towel clamps. DC laparotomy is not surgery,but a resuscitative procedure that should be done under ketamine anesthesiaby any trained doctor or nurse at district level. This technique is somethingthat needs to be observed before doing it, but done properly, can save lives.Second priority: Volume replacement, warming, and ketamineanalgesia The replacement should be warm: The physiological coagulation works best at 38.5 C, haemostasis is difficult at core temperatures below 35 .Hypothermia in trauma patients is common during protracted improvisedout-door evacuations – even in the tropics. It is easy to cool a patient butdifficult to re-warm, hence prevention of hypothermia is essential. Per oraland IV fluids should have a temperature at 40–42 C – using IV fluids at “roomtemperature” means cooling!Hypotensive fluid resuscitation: In cases where the haemostasis is insecureor not definitive, volumes should be controlled to maintain systolic BP at80–90 mm during the evacuation.Colloid solutions out – electrolyte solutions in! Recent careful reviews ofcontrolled clinical studies show slight negative effects of colloids comparedto electrolytes in resucitation after blood loss.Per-oral resuscitation is safe and efficient in patients with positive gag reflexwithout abdominal injury: Oral fluids should be low in sugar and salts;concentrated solutions can cause an osmotic pull over the intestinal mucosa,and the effect will be negative. Diluted cereal porridges based on localfoodstuffs are recommended.The analgesic choice: The positive inotropic effects, and the fact that it doesnot affect the gag reflex, makes us recommend ketamine in repeated IV dosesof 0.2 mg/kg during evacuation of all severe trauma cases.Think Safety - an injured healthworker is a patient
Primary Trauma CareSecondary SurveySecondary survey is only undertaken when the patient’s ABC’S are stable.If any deterioration occurs during this phase then this must be interrupted byanother PRIMARY SURVEY. Documentation is required for all proceduresundertaken. This will be covered in the Forum.The head-to-toe examination is now undertaken, noting particularly:Head examination scalp and ocular abnormalities external ear and tympanic membrane periorbital soft tissue injuries.Neck examination penetrating wounds subcutaneous emphysema tracheal deviation neck vein appearance.Neurological examination brain function assessment using the Glasgow Coma Scale (GCS) (see Appendix4) spinal cord motor activity sensation and reflex.Chest examination clavicles and all ribs breath sounds and heart tones ECG monitoring (if available).Abdominal examination penetrating wound of abdomen requiring surgical exploration blunt trauma – a nasogastric tube is inserted (not in the presence of facialtrauma) rectal examination insert urinary catheter (check for meatal blood before insertion).Head injury patients are suspected to havecervical spine injury until proven otherwise
Primary Trauma CarePelvis and limbs fractures peripheral pulses cuts, bruises and other minor injuries.X-rays (if possible and where indicated) chest X-ray and cervical spine films (important to see all 7 vertebrae) pelvic and long bone X-rays skull X-rays may be useful to search for fractures when head injury is presentwithout focal neurologic deficit order others selectively. NB chest and pelvis X-rays may be needed duringprimary survey.NOTES
Primary Trauma CareChest TraumaApproximately a quarter of deaths due to trauma are attributed to thoracic injury.Immediate deaths are essentially due to major disruption of the heart or of greatvessels. Early deaths due to thoracic trauma include airway obstruction, cardiactamponade or aspiration.The majority of patients with thoracic trauma can be managed by simplemanoeuvres and do not require surgical treatment.Respiratory distress may be caused by: rib fractures/flail chestpneumothoraxtension pneumothoraxhaemothoraxpulmonary contusion (bruising)open pneumothoraxaspiration.Haemorrhagic shock due to: haemothorax haemomediastinum.Rib fractures: Fractured ribs may occur at the point of impact and damage to theunderlying lung may produce lung bruising or puncture. In the elderly patientfractured ribs may result from simple trauma. The ribs usually become fairly stablewithin 10 days to two weeks. Firm healing with callus formation is seen after aboutsix weeks.Flail chest: The unstable segment moves separately and in an opposite directionfrom the rest of the thoracic cage during the respiration cycle. Severe respiratorydist
Primary Trauma Care Manual Standard Edition 2000 A Manual for Trauma Management in District and Remote Locations ISBN 0-95-39411-0-8 Published by Primary Trauma Care Foundation North House, Farmoor Court, Cumnor Road, Oxford OX2 9LU Email: admin@primarytraumacare.org To be copied with permission from the publisher.
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
LEVEL I PEDIATRIC TRAUMA CENTER The Level I Regional Pediatric Trauma and Burn Center at Children’s Hospital Colorado is a large, multi-disciplinary program. We provide timely, comprehensive, cost- . Trauma/Burn Medical Director Trauma/Burn Program Manager Trauma Coordinators Trauma Registrars Staff Assi
Historical trauma - Cumulative emotional and psychological wounding from massive group trauma across generations, including lifespan Historical trauma response (HTR) is a constellation of features in reaction to massive group trauma, includes . historical unresolved grief (similar to Child of Survivors Complex re: Jewish Holocaust survivors and
Kern County Emergency Medical Services Division 4 Trauma Policies and Procedures Effective Date: 07/01/2015 V. PREHOSPITAL TRAUMA SYSTEM ACTIVATION A. If a trauma patient meets the “Trauma Triage Criteria”, the Kern County Trauma Care System shall be activated as follows: 1. The following personnel are authorized to triage and then activate .
Connie J. Mattera, M.S., R.N., EMT-P I. Epidemiology of chest trauma A. Incidence 1. Chest injuries are common occurrences following blunt and penetrating trauma. 2. Isolated chest trauma is uncommon; the majority of these patients will have additional injuries. 3. Prevention efforts a major key 4. Thoracic trauma accounts for ⅓ all trauma .
Modern Approaches to Management *Separated Bureaucracy from Classical School. Lawal (2012) 1. Classical School of Management 2. Organic or Neo-Classical School (Human Relations and Behavioural Theories) 3. System and Contingency School 4. Dynamic Engagement Era * Agreed with Stoner et al. (2004) by Identifying New School (No. 4) Robbins and Coulter (2009) 1. Classical Approach 2. Quantitative .
