Management of the Trauma Patient
WSAVA 2002 Congress
R. Brühl-Day, Méd Vet, Dipl SA Surgery
Facultad de Ciencias Veterinarias-Universidad de Buenos Aires
Buenos Aires, Argentina
rbday@fvet.uba.ar

Initial assessment

Team work is the name of the game and within a team every member has to know his or her assignment.

Blunt trauma

 Car accidents. Direct impact?

 Fall from a height or high rise syndrome

 Kicks

Penetrating trauma

 Bites

 Projectiles

 Stabbing

 Because it may be possible not to have another chance to change an erroneous initial treatment it is important not to skip or mistakenly assess the vital signs.

 In a patient with severe trauma initial assessment is made at the same time as other things are initiated to stabilize the patient. Preparedness for fluid therapy and shock treatment are started at the same time the patient is being evaluated. a detailed history of the trauma incident may provide vital clues. Time lapse since the trauma occurred is an important information that has to be asked to the owners. Many times because of nervousness the time lapse cannot be thoroughly determined, but whenever possible is a fine data and can help with some actions to be taken. Clipping the hair may facilitate visualization of bruises.

 Hypoxia and hemorrhage are two of the main causes of death among traumatized patients. In every traumatized patient, in shock and with no evidence of external bleeding any accumulation of blood must be assessed

 The physical evaluation must be done in an orderly fashion:

 Respiratory, cardiovascular, nervous, digestive, and musculoskeletal systems

 Inspection: initial overall observation of the patient

 Palpation: superficial and deep.

 Percussion: free fluid?, gas?

 Auscultation: borborigmus?, ileus ? Decreased vesicular murmur, muffled sounds?

 Other: draw blood for preliminary lab data?, bladder catheterization?, rectal palpation?

Preliminary assessment

 Rectal temperature,

 Heart rate and respiratory rate

 Color of mucous membranes

 Capillary refill time and hydration status

 Pulse quality

 External bleeding?

 Skin integrity

 Level of consciousness

Respiratory system

 Adequate ventilation?

 Imbalance between ventilation and perfusion?

 Upper airway alterations? Is there a need for tracheotomy?

 Pneumothorax? Think about thoracocentesis

 Trauma or lung injuries?

 Ruptured diaphragm?

 Hemo, hydro or chylothorax?

 Does any lesion require immediate surgery?

Cardiovascular system

 Any external visible hemorrhage?

 Any hypovolemic or shock signalment?

 Rhythm and pulse characteristics.

 Cardiac auscultation, what can we find out from that?

 Venous distention?

 IV catheter placement.

 Draw a blood sample.

 Replace any volume deficiency.

 Does any lesion require immediate surgery?

Nervous system

 Level of consciousness? Alert, ambulates, reflexes.

 Unconscious?

 Depressed, paretic, paraplegic?

 Has the patient received any medication that may alter the examination?

 Any perceived changes in the central or peripheral nervous system?

 Does any lesion require immediate surgery?

Digestive system

 Abdominal trauma can be a challenge to diagnose. It is highly important to keep in mind a suspicion for abdominal trauma every time we deal with traumatized patients.

 Any signs of acute hemorrhage? Ruptured spleen? Other hemorrhage sources like kidneys, liver, mesenteric vessels?

 Gl tract assessment.

 Abdominal viscera exploration (i.e., urinary bladder, ureters, gall bladder, pancreas). Prepare for diagnostic peritoneal lavage (DPL) or abdominocentesis.

 Possible peritonitis?

 Need for immediate exploratory laparotomy?

Musculoskeletal system

 Gait abnormalities or lameness

 Any visible signs of open fracture or luxation?

 Joint exploration

 Tendon laceration or avulsion?

Ancillary diagnostics

 When to order an X ray? (i.e., X-rays must be taken if possible before any centesis or DPL is performed since these procedures may introduce air into the abdominal cavity.

 Plain or contrast studies?

 Ultrasound?

 CT scan or MRI? Do we always need such expensive studies?

Main sources for trauma In Dogs

 Hit by car

 Dog fights / bites

 High rise syndrome

 Mistreatment, kicks, punches and other type of blows

 Penetrating wounds (bullets, knives, etc.)

Main sources for trauma in Cats

 Fights / bites

 Mistreatment, kicks, punches and other type of blows

 Penetrating wounds (bullets, knives, etc.)

 High rise syndrome

 Hit by car

Thorax

Assess and palpate for:

 Thoracic movement and respiratory pattern

 Rib fractures. Do we need to alleviate pain?

 Flail chest? Support bandages?

 Penetrating wounds

 Locate heartbeat

Abdomen

 Look for pain.

 Evidence for free fluid or abdominal distention.

 Diagnostic peritoneal lavage more accurate (20ml/kg of warm saline or lactated Ringers).

 Identify every palpable organ whenever possible.

 Retroperitoneal space evaluation.

Spine and appendages

 Temperature of extremities

 Evaluate for fractures or luxations

 Check for wounds or any evident deformity

 Retroperitoneal space can be involved in spinal and / or pelvic fractures.

Nervous system

 Evaluate aptitude to stand up and walk

 Position of the extremities and presence of paresis / paralysis

 Flaccidity or rigidity

 Cranial and peripheral reflexes

Head and neck

 Blood loss coming from the natural openings?

 Look after injuries in the head, eyes, ears, nose and nostrils

 Check for pain and range of motion of the head

 Open the mouth and explore it. Look after tongue or dental lesions. Remember palate fractures in high rise syndrome.

 Airway obstruction due to inspissated saliva and blood?

Exploratory surgery

 When?

 Patient stabilization goes first on every occasion possible, but if stabilization is not working and / or the patient not responding, do not waste time.

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Rodolfo Brühl-Day, Méd Vet, Dipl SA Surgery
Facultad de Ciencias Veterinarias-Universidad de Buenos Aires
Buenos Aires, Argentina


MAIN : Critical Care : Trauma Patient
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