Primary Trauma Care

2. Primary Trauma Care
Dr Imran Javed.
Associate Prof Surgery.
Fiji National University.

5. Introduction
• There are notable disparities in the outcome of trauma
care around the world.
• 60% of preventable trauma associated deaths occur in
the first 24 hours.
• Difficulties facing trauma care in developing countries
include manpower development, infrastructure,
availability of equipment and organization.
• Much of the improvement in trauma care has resulted
from better organization of trauma care services.
• The main focus of this module is appropriate life-saving
management in the first few hours following trauma.

11. Learning Outcomes
• Discuss the burden of trauma
• Describe the concept of triage
• Identify common life-threatening injuries
• Adequately resuscitate and re-evaluate the trauma patient
• Manage common life-threatening injuries effectively
• Perform a secondary survey to plan the next stage of care

14. Triage in the emergency room
• The first is quiet and appears calm and still
• The second is in excruciating pain from an obvious
femoral fracture with the foot twisted in the opposite
direction
• The third patient is screaming at the site of his clothes
soaked with blood from an extensive scalp laceration
• The fourth patient walks-in complaining of right sided
chest pain and difficulty with breathing

16. Managing the severely injured patient
Initial management (resuscitation)

18. Catastrophic hemorrhage:
the exception to “A,B,C,D,E”
• This is life threatening hemorrhage, often due to
traumatic amputation or crush injury to the
limbs. Bleeding is usually massive and the patient
may be on the point of exsanguination.
• It is necessary to rapidly control the hemorrhage
before assessing the airway.
• The bleeding vessel may be ligated if it can be
identified. If not, this may be one of the
exceptional cases when a tourniquet may be
used. However, the duration of application must
be noted.

19. Airway management: The conscious patient
• Speak to the patient.
• Does he respond? If he responds in a normal voice giving a
logical answer then he most probably can control his airway.
• However, cervical spine injury (CSI) may be present. First,
inspect the neck meticulously for wounds and other
abnormalities.
• Cover any penetrating wounds with clean gauze and plaster.
• Then, immobilize the cervical spine using one of these
methods:
• MILS (Manual in-line stabilization)
• Cervical collar
Spinal board, head blocks, sandbags

20. Primary Survey - Airway
• Maintain C-spine precautions
• Clear any obstructions
• Jaw thrust instead of head tilt chin lift
• Endotracheal intubation for airway protection
or expected clinical course (ie obstruction
from blood or vomitus, neck hematoma, facial
burns or trauma, GCS 8 or less, combative
patient, potential for airway compromise
while out of department.)

21. Primary Survey - Breathing
• Auscultation for bilateral breath sounds
• Palpation for subcutaneous emphysema
-needle decompression followed by chest tube for
pneumothorax
• Inspection for flail chest
• Observation of respiratory rate, oxygen
saturation, and overall work of breathing
-mechanical ventilation for inadequate ventilation
or to decrease work of breathing

23. Primary Survey - Circulation
• Check peripheral pulses, heart rate, BP,
pulse pressure, capillary refill, cyanosis
• All hypotensive trauma patients are
assumed to be in hemorrhagic shock
• 2 large bore peripheral IV’s (at least 18
gauge)
• Control external bleeding

26. Primary Survey - Circulation

27. Primary Survey - Circulation
• Begin volume resuscitation with liter boluses of
crystalloid for class I or II hemorrhage.
• Begin crystalloid and blood for class III or IV
hemorrhage.
• O- blood until type specific is available
• Constant reevaluation is paramount
• If class I or II is patient still showing signs of shock
after 3L of crystalloid, begin blood
• “3:1 rule” 3cc crystalloid for every 1cc of blood
loss

28. Primary Survey - Circulation
• 5 Places life threatening hemorrhage can
occur
• -Chest
• -Abdomen
• -Pelvis
• -Thighs
• -Externally

29. Primary Survey - Circulation
• Cardiac Tamponade can cause hypotension
with little blood loss.
• Becks triad: hypotension, distended neck
veins, muffled heart sounds
• Easily confirmed with ultrasound
• Pericardiocentesis
• Pericardial Window.

32. Primary Survey - Disability
• Quick assessment of ability to move all
extremities
• Glasgow Coma Scale.

34. Primary Survey – Exposure
• Completely undress the patient and
inspect the entire patient from head to
toe both front and back.
• Maintain spinal precautions during
logrolling
• Inspect both axillae and Perineum.
• Warm blankets!!!

35. Secondary Survey
• Head to toe evaluation once any derangements in
primary survey have been addressed.
• AMPLE History
• -Allergies
• -Medications
• -Past medical history (LMP, Td, transfusions)
• -Last meal
• -Events leading up to trauma

36. Imaging – Plain Films
• Choice of imaging modality depends on
nature of injuries and stability of patient.
• Knowledge of injury mechanism and index of
suspicion most important
• Can be performed at bedside
• Useful for rapid identification of
pneumothorax, hemothorax, fractures and
locating ballistics

38. Imaging – Ultrasound
• Quick
• Can be performed at bedside
• FAST: Focused Assessment with
Sonography for Trauma
• Rapid examination to identify free
intraperitoneal fluid and/or pericardial
fluid

40. Imaging – CT
• Detailed
• Requires patient to leave the department
• Necessary for head trauma

41. Disposition
• To the OR
• -Unstable patients with blunt or penetrating
abdominal trauma or chest trauma. Hemothorax
with >1500 cc of blood out initially. Surgical
injuries identified with imaging.
• Admission
• -Nonsurgical, high-risk injuries
• Discharge
• -Stable patients, minor or no injuries
identified.