trauma

1. Trauma – initial assessement and
management.

2. POLYTRAUMA
• A clinical syndrome where a patient
sustained serious injuries
involving ≥2 major organ &
physiological systems

3. Approach to trauma victims
• Different from non-trauma patients
• Treat the greatest threat to life FIRST
• Treatment given before definitive
diagnosis made

4. • If you are critically injured, you’ll have
less than 60 minutes to survive.
• You might not die right then; it may be
three days or two weeks later -but
something has happened in your body
that is irreparable” .
• Dr. R. Adams Cowley
• “Father of Trauma Medicine”

6. seconds to minutes
minutes to hours
GOLDEN HOUR
several days or weeks

7. Introduction
Survival depends on
assessment skills
Good assessment results from
An organized approach
Clearly defined priorities
Understanding available
resources

8. Initial Assessment (Primary Survey)
Find and correct life threats
Most obvious or dramatic injury usually is NOT what is
killing the patient!
If life-threat is present, CORRECT IT!
With critical trauma you may never get beyond primary
survey

9. Components of Trauma Care in polytraumaComponents of Trauma Care in polytrauma
patients :patients :
1) Triage & scene assessment
2) Primary Survey
3) Secondary Survey
4) Re-evaluation.
5) Definitive Care
6) Rehabilitation

10. Initial Assessment
InjuryInjury
ReevaluationReevaluation
ResuscitationResuscitation
AdjunctsAdjuncts
Primary SurveyPrimary Survey
AdjunctsAdjuncts
Secondary SurveySecondary Survey
ReevaluationReevaluation
Optimize patientOptimize patient
statusstatus
TransferTransfer

11. 6 LETHAL CONDITIONS IN
POLYTRAUMA
ATOM FCATOM FC
1) AIRWAY OBSTRUCTION
2) TENSION PNEUMOTHORAX
3) OPEN PNEUMOTHORAX / CHEST WOUND
4) MASSIVE HEMOTHORAX
5) FLAIL CHEST
6) CARDIAC TAMPONADE

12. D - DangerD - Danger
R – Response - AVPUR – Response - AVPU
A -A - AIRWAY & CERVICAL
SPINE CONTROL
B -B - BREATHING &
VENTILATION
C -C - CIRCULATORY FUNCTION
& HEMORRHAGE CONTROL
D -D - DISABILITY &
NEUROLOGICAL STATUS
E -E - EXPOSURE & UNDRESS
COMPLETELY

13. Airway
• establishing verbal contact with the patient -
clear phonation by the patient establishes that
the airway is patent.
–Noisy breathing is obstructed breathing
• But all obstructed breathing is not noisy

14. airway
• Anticipate airway
problems with
– Decreased level of
consciousness
– Head trauma
– Facial trauma
– Neck trauma
– Upper chest trauma
• Open it, Clear it, Maintain
it
Look for :
- Snoring, gurgling, stridor or
hoarseness
- Use of accessory muscles
or “seesaw “ breathing.
- Agitation or obtundation
- F.B ( airway debris, blood,
vomitus, teeth….
- Unconscious.
- Cyanosis.
- The likehood of difficult
airway

15. AIRWAY MANAGEMENT
Jaw Thrust-Chin lift / modified jaw thrust
-Remove F.B & suctioning
-Oropharyngeal or Nasopharyngeal airway
-Laryngeal mask airway
-Definitive airway
-Reassess frequently
• If no gag reflex, prepare for intubation
- All patients with GCS <9 need intubation
- IN Suspected C-spine injury do not head tilt chin lift

16. Definitive airway
Three Varities:
1-Orotracheal tube
2-Nasotracheal
tube
3-Surgical airway.
-Cricothyroidotomy
-Tracheostomy

17. Breathing
Look
Listen
Feel

18. • airway patency does not insure adequate
ventilation
LOOK
• nature of the injury: maxillofacial
trauma/airway burns - potential for airway
compromise, obvious airway or chest
trauma (sucking chest wounds, flail
segments), cyanosis
• tachypnea, use of accessory muscles of
respiration or evidence of tracheal shift

19. LISTEN
• stridor  upper airway compromise.
• hyperresonance to percussion/lack of air
entry  pneumothorax
• dullness to percussion/lack of air entry 
hemothorax.
• bowel sounds in the chest  ruptured
diaphragm.

20. FEEL
• hand over the mouth - feel for air exchange.
• Insertion of a finger - sweep to clear the mouth of any
foreign bodies (especially dislodged teeth) and to evaluate
for evidence of maxillofacial trauma.

21. TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX
 Air enters pleural space – then No exitAir enters pleural space – then No exit
 Collapse of affected lungCollapse of affected lung
 Impaired venous returnImpaired venous return
 Impaired ventilation of unaffected lungImpaired ventilation of unaffected lung

22. Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

23. TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX
 SIGNSSIGNS
• Tracheal Deviation
• Absence of breath sounds - Unilateral
• Distended Neck Veins
• Cyanosis – Late
 DIAGNOSISDIAGNOSIS - Clinically, NOT
Radiological
 MANAGEMENTMANAGEMENT
• Needle Thoracocentesis

26. NEEDLE
THORACOCENTESIS
2nd
Intercostal space
Mid Clavicular Line

28. OPEN PNEUMOTHORAX
PATHOPHYSIOLOGY
* Chest wall defect
* Collapsed lung
* Ball valve defect
Implanted object eg knife - natural seal
DO NOT REMOVE THE OBJECTDO NOT REMOVE THE OBJECT

30. MASSIVE HAEMOTHORAXMASSIVE HAEMOTHORAX
 More than 1500 ml of blood lost intoMore than 1500 ml of blood lost into
the chest cavitythe chest cavity
OR 600 ml/6H (600 ml/H for 1 hour OR 100
ml/H for 6H OR 200 ml/H for 3H by chest tube
 Signs:
Dyspnoea, Hypoxia, Dullness & absence of
breath sounds

31. FLAIL CHESTFLAIL CHEST
 segment of chest wall does not have bony
continuity with the rest of the thoracic cage
(e.g. multiple rib fractures)
EFFECTEFFECT
 Severe disruption of normal chest wall movement.
 ‘paradoxical motion’
 Severe lung/pulmonary contusion which lead to
hypoxia

32. MANAGEMENTMANAGEMENT
 Adequate ventilation & OxygenAdequate ventilation & Oxygen
 Volume restorationVolume restoration
 AnalgesiaAnalgesia

33. How to Diagnose CardiacHow to Diagnose Cardiac
TamponadeTamponade
• Mechanism of injury
• Raised JVP despite blood loss
• Signs of impaired cardiac performance:
Poor peripheral perfusion
Anxious, obtunded patient
Low pulse volume
Distant or absent heart sounds
• BECK’S TRIAD
• -- Elevated JVP
• - Muffled Heart Sounds
• - hypotension

34. Circulation
• warmed intravenous infusions
Control:
• external hemorrhage
• internal hemorrhage:
Pelvic binders

36. Circulation
Does patient have radial pulse?
Absent radial = systolic BP < 80
Does patient have carotid pulse?
Absent carotid = systolic BP < 60
Serious external bleeding?
Direct pressure (hand, bandage)
Tourniquet as last resort

37. Disability (CNS Function)
–Level of
consciousness =
Best brain perfusion
sign
–Use AVPU initially
–Check pupils
• The eyes are the
window of the CNS
–Decreased LOC =
• Brain injury
• Hypoxia
• Hypoglycemia
• Shock
–NEVER think drugs,
alcohol, or
personality first

38. Neurological Stability
• decreased level of consciousness is considered to be
intracranial pathology until proven otherwise (drugs,
alkohol)
• brief neuro exam (done during the primary survey):
A - Alert
V - responds to Verbal stimuli
P - responds to Painful stimuli
U - Unresponsive
• Glasgow Coma Scale (GCS):
GCS < 8 requires definite airway intervention to prevent
aspiration pneumonitis, to insure adequate oxygen
delivery and to avoid hypercarbia.
If a patient is responding only to painful stimuli or is
unresponsive/unconscious, the GCS is or has a high
likelihood of being less than 8.

39. Exposure and
environmental control
• Fully expose the patient whilst assuming that other injuries
are present
• Prevent hypothermia by controlling room temperature or
covering the patient with blankets immediately after
examination.
• To expose the patient, use scissors to cut along the seams of
clothes to avoid worsening any injury and ensure minimal
movement of the patient.
• Do not forget to do a rectal examination whilst log rolling
the patient
• Findings on rectal examination
• Rectal bleeding or bone spicules suggest a pelvic fracture
• A high riding prostate suggests urethral injury
• You may miss injuries if you do not fully expose the
patient

40. • Expose and Examine
–You can’t treat what you don’t find!
–If you don’t look, you won’t see!
–Remove ALL clothing from critical patients
ASAP
–Avoid delaying resuscitation while disrobing
patient
–Cover patient with blanket when finished

41. PELVIC SPRING TEST

42. Secondary Survey
• History and Physical Exam
• You WILL get here with MOST trauma patients
• Perform ONLY after primary survey is completed and life threats
corrected
• History
– SAMPLE history
• S = Signs and symptoms
• A = Allergies
• M = Medications
• P = Past medical history
• L = Last oral intake
• E = Events leading up to incident

43. Secondary Survey
PATMED
 P - Pulmonary contusion
 A - Aortic dissection
 T - Tracheo-broncho fistula
 M - Myocardial contusion
 E - Esophageal perforation
 D - Diaphragmatic disruption

44. • Physical Exam
– Stepwise, organized
– Head to Toe, organized approach
– Every patient, same way, every time
– Superior to inferior; proximal to distal
– Look--Listen--Feel
• Physical Exam
– Assessment of extremities MUST include:
• Pulses
• Skin color
• Skin temperature
• Capillary refill
• Motor function
• Sensory function

45. • Rapid Trauma Assessment
• DCAP-BTLS
• D - Deformities
• C - Contusions
• A - Abrasions
• P - Punctures/Penetrations
• B - Burns
• T - Tenderness
• L - Lacerations
• S - Swelling

46. • Pediatric considerationsPediatric considerations
(SCIWORA)(SCIWORA)
• SCIWORA –SCIWORA – SSpinalpinal
CCordord IInjurynjury WWithithOOutut
RRadiographicadiographic
AAbnormalitybnormality
• CONTRAINDICATIONS TO
LOGROLL:
• Pelvic Instability
• Bilateral Femur Fractures

47. (1) the hepatorenal recess (Morison pouch),
(2) the perisplenic view, (3) the subxiphoid
pericardial window, and (4) the suprapubic
window (Douglas pouch). If an extended
FAST (E-FAST) examination is performed,
views of (1) the bilateral hemithoraces and
(2) the upper anterior chest wall should also
be obtained

48. FAST SCAN

49. Always Work in A TeamAlways Work in A Team