2. +
CASE:
A 25 year old is brought
to casualty with history of
fall from a height of 20
feet. He landed on a pile
of bricks. Fortunately
there was no head injury.
He is complaining of
severe abdominal pain.
On examination he is
conscious; his pulse is
110/minute, BP 90/60
mmHg. There is no
external wound. However
has abrasions in left
upper quadrant and left
lower chest.
3. +
MECHANISMS OF
TRAUMA
Trauma can be classified
in type by causation and
by effect
Blunt , e.g. car bonnet
Penetrating , e.g. Knife
Blast , e.g. Bomb
Crush , e.g. building
collapse
Thermal
4. +
Deaths from trauma show three
peaks:
Immediate
death :
o
Occurs within seconds
o
Cause : head injury , heart injury or aortic injury
o
These deaths are not preventable
5. +
Early death:
o
Begins an hour or two after injury
o
Cause: subdural and epidural hematomas , hemo or
pneumothorax , organ rupture or blood loss
o
Often preventable
o
This period is called the GOLDEN HOUR during which
prompt intervention can save a life
6. +
Late
death:
o
Occurs many days after injury
o
Cause: sepsis or multi-organ failure
o
Prompt treatment of shock and hypoxemia during GOLDEN
HOUR can reduce these deaths
7. STEPS IN ADVANCED
TRAUMA LIFE SUPPORT:
Prehospital care
Primary survey with simultaneous resuscitation:
identify and treat what is killing the patient
+
Secondary survey : proceed to identify all other
injuries
Definitive care: develop a definitive management
plan
9. Airway
maintenance
Control of
external bleeding
& shock
Immobilization
of the patient
Communication
with receiving
hospital &
immediate
transport to the
closest,
appropriate
facility
History taking
+
10. +
Prior to arrival:
Ensure senior emergency medical and nursing staff are aware of all
available details of the case.
Call Trauma Team (Trauma surgeon , Anaesthetist , Nurses ,
Emergency physician , Respiratory therapist , Radiologist ,
Surgical subspecialists)
Delegate specific tasks to appropriate individuals.
Check the resuscitation equipment and prepare intravenous lines and
fluids.
If possible, estimate the patient's weight using the formula (Age + 4) x 2
(or 3 x Age for those over 9 years) and calculate:
1) The amount of fluid bolus at 20 ml/kg
2)The endotracheal tube size (age/ 4) + 4
3)Any other drugs likely to be needed
11. +
On arrival:
Immediately perform a primary survey by assessing and
managing the patient's airway, with cervical spine
stabilisation, breathing and circulation.
Obtain a history, if possible, from the attendents or
ambulance officers e.g. type of trauma, speed of the vehicle,
height of the fall, restraints or safety equipment used,
whether other people were injured.
Obtain information regarding any treatment or interventions
to date.
13. +
Identified the life-threatening conditions
and simultaneously manage:
A: Airway maintenance with cervical spine protection
B: Breathing and ventilation
C: Circulation with hemorrhage control
D: Disability ( Neurologic status )
E: Exposure / Environmental control: Undress the patient &
prevent hypothermia
14. +
A : Airway and C- spine
* Talk to the patient
A patient who can speak clearly must have a clear airway
Unconscious patient may require airway and ventilatory
assistance.
The cervical spine must be protected during endotracheal
intubation if a head, neck or chest injury is suspected.
Airway obstruction is most commonly due to obstruction by
the tongue in the unconscious patient.
Hoarsness or pain with speaking indicate
laryngeal injury.
15. +
* Assess airway
The signs of airway obstruction may include:
snoring or gurgling ( foreign body , aspiration )
stridor or abnormal breath sounds
agitation (hypoxia)
using the accessory muscles of
ventilation/paradoxical chest movements
cyanosis.
16. +
* Consider need for advanced airway
management
Indications for advanced airway management techniques for
securing the airway include:
o
persisting airway obstruction
o
penetrating neck trauma with haematoma (expanding)
o
Apnoea
o
Hypoxia
o
severe head injury
o
chest trauma
o
maxillofacial injury
17. Advanced airway
management:
*
* If obstruction persists:
- Chin lift and Jaw thrust
- Consider C-spine injury in
every patient until proven
otherwise
+
•Endotracheal intubation if:
- above don’t help
unconscious patient
- airway swelling or burns
-GCS less than 8
* Surgical Cricothyrotomy (if
there is severe facial or neck
injury)
18. +
B: Breathing and ventilation
* Inspection (LOOK) of respiratory rate is
essential. Are any of the following present
Cyanosis
penetrating injury
presence of flail chest
sucking chest wounds
use of accessory muscles
19. + * Palpation (FEEL) for
tracheal shift
broken ribs
subcutaneous emphysema
percussion is useful for diagnosis of haemothorax (dull)
and tension pneumothorax (hyper-resonant)
20. + * Auscultation (LISTEN) for
pneumothorax (decreased breath sounds on site of
injury)
Detection of abnormal sounds in the chest.
Give 100% oxygen (if available, via self-inflating bag or
mask)
injury
1.
2.
3.
4.
that may acutely impair ventilation
Tension pneumothorax
Flail chest with pulmonary contusion
Massive haemothorax
Open pneumothorax
21. + Tension
pneumothorax
* Respiratory distress
* Over inflated hemithorax and
visibly splayed ribs
* Ipsilateral Hyperresonant
percussion note
* Ipsilateral reduce or absent breath
sounds
* Treacheal deviation
* Distended neck veins
Management: Immediate needle
decompression in second Intercostal
space midclavicular line
22. + Open
pneumothorax
* Ipsilateral reduced breath sounds
* Ipsilateral resonant percussion note
* Decreased expansion
* Penetrating chest wall injury
Management:
Cover defect - Sterile waterproof three
sided dressing secured on two sides to act
as a flutter valve.
Intercostal drain placed away from open
wound.
Surgical debridement and closure later.
23. + Massive
Hemothorax
* Hypotension due to blood loss
* Ipsilateral dullness to percussion
note
* Ipsilateral absent or reduced
breath sounds
* Ipsilateral decreased chest
movements
Management:
Infusion of fluids through large bore
IV cannula before draining
Large bore intercostal drain for
adults
24. + Flial Chest
* Segment of chest looses bony
continuity with thoracic cage
* Moves paradoxically with
respiration and reduces tidal volume
Management: Analgesia for pain
Fluid management
Ventilatory support
25. C: Circulation and hemorrhagic
+
control
* Hemorrhagic control
Direct pressure for external hemorrhage
No tourniquet unless other methods are not effective in
controlling bleeding
Long bones splinted with external fixation
Pelvic binding or pneumatic anti-shock garment
Watch out for hypothermia, acidosis and coagulopathy
26. +
* Assessment for hypovolaemia
Check skin: color , clamminess and capillary refill time
Heart rate
Blood pressure
Pulse pressure
Conscious level
Connect an automatic BP recorder and ECG
Hypovolaemia is the commonest cause of shock in trauma
patients
27. +
*Vascular cannulization
Two Large bore IV cannulas: peripheral i.e. Femoral Vein
Central – Subclavian or Internal Jugular
Intraosseous in children
Draw
20ml blood for grouping and cross matching , analysis of
electrolytes and full blood count
28. + * Fluid resuscitation
Bolus of warm crystalloids
Surgical control of hemorrhage is better than aggressive
fluid resuscitation
Fluid resuscitation inhibits platelet aggregation , dilutes
clotting factors and raises BP
Altered cardiovascular response to hemorrhage in trauma
pts
Enough warm crystalloids to maintain a radial pulse
Blood may also be required
29. +
D : Disability
Glasgow Coma Scale
Pupilary reflexes
Monitor frequently to detect deterioration
Common causes for
deterioration
Hypoxia
Hypovolaemia
Hypoglycemia
Raised intracranial pressure
30. +
E : Exposure
Clothes should be cut to remove
Pt kept warm and covered with blankets
Log roll
Assess spine from base of skull to coccyx
Examine back for any signs of injury
Digital Rectal Examination:
Boney fragments
Rectal wall
Bleeding
Prostate
32. +
HISTORY
A. Allergies
M. Medications currently used + tetanus status
P. Past illness / pregnancy
L. Last meal / LMP
E. Events / Environment related to injury
33. +
HISTORY : MECHANISM OF INJURY
Blunt
Automobile collisions
Seat belt usage
Steering wheel deformation
Direction of impact
Ejection of passenger form the vehicle
Burns and Cold injury
Inhalation injury and
Hazardous
CO. intoxication in fire field
environment
34. +
Penetrating
Anatomy factors
Energy transfer factor
Velocity and caliber of bullet
Trajectory
Distance
