Early management

Airway management

Patients with pulmonary contusions are at high risk for respiratory distress and pneumonia. Methods should be implemented early on in the course of treatment to improve oxygenation and ventilation. The goal of treatment should focus on re-expansion of the actelactic regions through high PEEP.
Ventilation strategies should include:
  • Low Tidal Volume: (4-8mL/kg)
  • Limited plateau pressure <30mmHg
  • FiO2 level as low as possible to obtain SaO2 >90%
  • Optimal PEEP, incrementally added

Fluid resuscitation

Avoidance of hypovolaemia in trauma is a cornerstone of management. A balanced approach to fluid replacement is important, especially in establishing early treatment goals.14
Resuscitation goals:
  • The main goal of blood volume resuscitation in trauma is to preserve vital organ perfusion until bleeding can be controlled.
  • In immediate trauma care aim for a blood pressure greater than 90 mmHg systolic or a shock index less than 1 (HR/SBP).
  • Blood pressure goals for penetrating chest trauma or uncontrollable haemorrhage are generally lower than for blunt trauma in the absence of a major head injury. (SBP values less than 90 mmHg may be acceptable if cerebral perfusion is maintained).15
  • Tissue perfusion can be assessed in a number of ways. These include:
    • Skin color- pale and peripherally shut down versus mottled and blue.
    • Prolonged capillary refilling time.
    • Decreased conscious state- poor cerebral perfusion.
    • Arterial blood gases- acidosis is often mixed in severe chest injury, however increasing base deficit and increasing lactate are reliable indicators of tissue hypo-perfusion.
    • Decreased urine output takes time to become evident.
  • If possible, all blood/fluid administered to a major trauma patient should be warmed with a fluid warmer.

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Monitor

  • HR / RR / BP / SPO2 / GCS.
  • Reassess every 15/60 or more frequently if indicated.
  • Fluid Balance Chart – keep an accurate record of input / output.
  • Serial BG assessment of pH, base-deficit and lactate levels provide good monitoring of tissue oxygenation, circulatory status and response to resuscitation.

Administer

  • Tetanus Prophylaxis: updated in the case of significant or contaminated wounds. Tetanus immunoglobulin should be given to patients who have not received a complete primary immunisation.16
  • IV antibiotics: Recommended on insertion of an intercostal catheter and in penetrating trauma.

Wound Care

In a major trauma patient, early wound closure (pre-transfer) is not a priority.
  • Remove gross contamination and irrigate the wound.
  • Gain haemostasis through pressure and elevation where possible, ensure bleeding has ceased.
    Simple dressings with saline, gauze, combine and moderate compression bandages are generally adequate.
  • Suture simple wounds if time allows.
The priorities for further investigation and treatment may now be considered and a plan for definitive care established.