Trauma Management PPT for MBBS Students by Dr Anil Kumar , AIIMS, Patna.

1. Dr Anil Kumar
Assist Professor, Gen Surgery
(Renal Transplant, Bariatric Sx,
Endocrine Sx,
Trauma Surgery)
AIIMS-Patna

2. Objective to Learn
 Definition of Basic term
 Burden of Trauma in India
 What should be ideal protocol to overcome it?
 Expectations from others especially MBBS Students.
 To achieve good outcome in Trauma patients.
 Concept of scene safety & Triage
 Core Management of Trauma i.e ABCDE…..

3. Trauma:
 Trauma-Physical damage to the body
 -RTA
 -VIOLENCE
 -FALL
 -Others

4. EMERGENCY
 Definition-An event that will kill/disable one/many-where outcome
can be altered by TIMELY ACTION.
 DISASTER- If INJURY kills/disable many .
 Mass Casuality:No of pts & the severity of their injuries exceed the
capability of the hospital
 Multiple Casuality:No of pts & the severity of their injuries donot
exceed the capability of the hospital
 OUTBREAK-If ILLNESS kills/disable many .

5. Burden of Trauma
 A/C to Gururaj G. Report 2005:
 Hospitalization= 2.5 million
 Death = 1,10,000 Persons
 Economic loss = 3% of GDP

6. Burden of Trauma
 A/C to NCRB 2011
 Hospitalization= 4.0 million
 Death = 1,40,000 Persons
 One death in every 5 minutes
 10-30% of Hospital registration are due to RTI.
 Majority of Victims belongs to poorer section of society.

7. Burden of Trauma in 2020
 India will witness the death of > 2,50,000 pers.
 Hospitalization of > 4.5 million people.
 One death in every 3 minutes instead of current data
i.e one death every 4- 5 minute.

8. Reality
 Major problem of India is Trauma.
 76% of male age group of 15-44 years died/year
 No immunity
 Outcome is very well if treat it earliest and
systematically.

9. Reality of such Burden
 Recommendation is start treatment at scene site
 In our country - no such concept of Pre-Hospital Care
 In our country even Hospital care is not established
for trauma patients a/c to a standard protocol

10. Responsibilty
 Homogenous, Ideal & Standard protocol to Treat Trauma
patients.
 Upgrade the concept of pre-hospital care at community
level.
 Training to common people by Medical Students
 To make a Benchmark

11. Treatment Protocol
 SANKATMOCHAN.
 BLS ( Basic Life Support)
 ATLS( Advanced Trauma Life Support).
 ACLS(Advanced cardiovascular life support)

12. Best Protocol-ATLS
Advance Trauma Life
Support ------Best in
managing Trauma Patients.

13. Treatment Plan
 Preparation( Mainly Pre-Hospital)
 Triage
 Primary Survey
 Resuscitation
 Adjunct to 1* survey & Resuscitation
 Secondary Survey( Head to Toe exam and history)

14. Cont
 Adjunct to 2ndary survey.
 Continued Post-Resuscitation monitoring and re-evaluation.
 Definite care.

15. Preparation.
 Pre –Hospital.
 In –Hospital.
 Goggles
 Gloves
 Gowns/Apron
 Mask/Cap
 Shoe cover.

16. PRE-HOSPITAL PHASE
 Receiving hospital is notify first
 Start care at Scene site i.e Pre-Hospital Care
 Send to the closest and appropriate Trauma Centre.
 HOSPITAL-PHASE
-Advance planning for pt arrival

17. AIIMS-Patna effort.

18. AIIMS-Patna effort

19. QMRT(Quick Medical Response
Team ) Course

20. BLS-AIIMS Patna

21. Video on Pre-Hospital care 4
common people

22. PHTC for Dy.S.P of Bihar

23. TAAC-Trauma & Android Course for
Autodriver.

24. Purpose of these course:
 Educate every one to give Pre-Hospital care
 Make the maximum patients to reach upto hospital
 To reduce the mortality and morbidity

25. Protocol
Pre-Hospital Care Hospital
1 Scene safety & Response checking Preparation
2 Triage Triage
3 Primary Survey-ABCDE Primary survey-ABCDE
A Helmet Removal/ F.B Removal Resucitation
B Jaw Thrust/ Chin lift Maneuver Adjunct to Primary Survey
C Hemorrhage control Consider need for pt transfer
D IV Fluid Secondary Survey
E Spinal/# Immobilisation Adjunct to secondary survey
F Transport to closest & appropriate
hospital
Continuous monitoring
4 Definitive Care Definitive Care.

26. Scene Safety-First Priority

27. Scene Safety-First Priority

28. Methods of scene Safety- Shifting
Drags Carries
Clothes Drag Cradle-in arms Carry
Blanket Drag Pack-strap Carry
Elevated arm-to-arm Drag Extremity Carry
Fire Fighter Drag Fire-Fighter Carry
Seat Carry
Supporting Carry
Chair Carry

29. Clothes Drag

30. Blanket Drag

31. Elevated arm-to-arm Drag

32. Fire Fighter Drag

33. Cradle-in-arm Carry

34. Pack Strap Carry

35. Fire-Fighter Carry

36. Extremity Carry

37. Seat Carry

38. Supporting Carry

39. Chair Carry

40. Stretchers
 Portable stretcher
 Basket Stretcher
 Stair Stretcher
 Backboards

41. Portable stretcher

42. Basket stretcher

43. Stair stretcher

44. Backboard

45. Response Check( Tape & Talk)

46. http://www.futurefd.com/images/mci_planecrash.jpg
http://www.buscrash.net/wp-content/uploads/2011/05/Bus-Crash1.jpg
http://aditty.files.wordpress.com/2010/03/women-drivers-car-pile-up.jpg http://cryptome.org/cn/cn-quake3/pict51.jpg

47. Triage
 Sorting/Prioritizing of patients in an MCI based
on the severity of their injuries or no of the pts.
 Goal = the greatest benefit for the greatest number of
patients
 Triage should be easy and fast.

48. START Triage
 One system of triage is called “START”
 START stands for “Simple Triage And Rapid Treatment”
 START categorizes patients into 4 groups based on
breathing, circulation, and mental status
 Red, Yellow, Green, and Black
 60 seconds per patient

49. Triage
 Breathing – yes or no?
 NO: Open airway with Jaw Thrust/Chin lift
 If patient begins to breathe = RED
 Keep airway open (recovery position)
 If patient does not begin to breathe = BLACK (Dead)
 YES = Fast or not fast?
 Breathing fast – RED
 Breathing normally – YELLOW

50. Triage
 Circulation – only check if the patient is
breathing
 Look for severe bleeding and stop it
 Ask for help if necessary
 Severe bleeding = RED
 All others = YELLOW

51. Triage
 Mental Status – only check if the patient is
breathing
 If patient is unconscious or cannot follow simple
commands= RED
 If patient can follow simple commands= YELLOW

52. Marking or “Tagging Patients”
 Official tags may not be available.
 Write the classified colour on the patients forehead or
upper arm
 If enough assistance is available, designate areas as Red,
Yellow, Green or Black and move the patients to those
area.

53. Priority of Transport
 Red – Transport FIRST
 Need immediate care!
 Yellow – Transport AFTER Red
 Need urgent medical care
 Can delay up to 1 hour
 Green - The “walking wounded”
 Care can be delayed up to 3 hours
 Black - Dead, or expected to die soon no matter what
care you provide

54. Benefit of Triage
 Prevent avoidable death( Red area pt)
 Avoid mis-using assets on hopeless cases.(Black)
 Avoid to miss any visible ongoing bleeding
 Proper medical t/t with a minimal time frame.

55. Remember: SRTT
 Scene Safety
 Response Checking
 Triage
 Transport.

56. Primary Survey
 Airway with cervical spine protection
 Breathing and ventilation
 Circulation with Hemorrhage control
 Disability: GCS
 Exposure(Undress)/Events with Hypothermia control

57. HISTORY: only AMPLE
 A - Allergy
 M- Medication currently used
 P – Past Illness
 L – Last meal taken
 E – Events.

58. Air way with C-Spine Protection
 Helmet Removal
 Cervical Collar
 Foreign Body Removal
 Jaw Thrust/Chin Lift Maneuver
 In advanced setting/Hospital – Airway & ET Intubation

59. Helmet Removal

60. Cervical collar
 Cartoon
 Paper Roll
 Brick
 Blanket
 Socks with paper inside it
 Anything that you are getting at scene site.
 Purpose : immobilize the spine

61. Cervical collar

62. Cervical collar

63. Proper Cervical collar- Hospital

64. In Patient with low GCS-Jaw
Thrust/Chin Lift
 Tongue can fall backward
 Can obstruct the hypopharynx
 Can be managed by- Jaw Thrust
-Chin Lift
 Don't do Head tilt in Trauma patient .

65. Jaw Thrust

66. Chin Lift

67. In advanced setting

68. ET –Intubation-G-MATHS
 GCS < 8
 MF Injury
 Aspiration risk( Bleeding/vomiting)
 Tracheal Injury
 Hematoma over neck
 Stridor

69. ET –Intubation –If Facility available

70. Air way……..
 Best way=communicate verbally
 Mc cause of airway obstruction- Tongue fall
 Techniques to open the airway=1.Chin lift maneuver. 2.Jaw
thrust maneuver
 Intubation is the definitive Airway
 C-Spine Protection is mandatory.

71. B=Breathing & Ventilation
 Adequate gas exchange to maximize oxygenation and
CO2 elimination.
 Ventilation- adequate function of the LUNGS, CHEST
WALL & DIAPHRAGM.
 Exposed the chest-
INSPECTION,PALAPTION,PERCUSSION &
AUSCULTATION

72. Problem in B
 Tension Pneumothorex
 Flail chest with pulmonary contusion
 Massive hemothorex and
 Open Pneumothorex
 T/T= Almost same- Needle decompression/ CHEST
TUBE, Ventilatory support.

73. Circulation & Hge Control:
 Hemorrhage – predominant cause of death in RTI.
 Rapid & accurate assessment is essential.
 Remember Floor & 4 More Clap to look the bleeding.
 4 More( CLAP) – Chest
- Long bones( Femur & Humerus)
- Abdomen
- Pelvis

74. MC Organs injured in BTA
 Solid Organs is the most commonly injured in BTA.
 MC organ – Injured in BTA is –Spleen
 2nd MC Organ Injured in BTA – Liver
 3rd MC organ Injured in BTA - Kidney

75. MC Organs injured in Penetrating
Trauma Abdomen(PTA)
 Mc organ i.e Small Intestine (Cos of Larger S.Area)
 2nd MC organ is Liver
 3rd MC organ is Colon.

76. Elements of Clinical Observation
 Level of Consciousness: Altered cos of Low BV.
 Skin Color : CRT( Capillary Refill Time) & Ashen,
Gray Facial Skin with White extremity.
 Pulse : Usually Either Carotid or Femoral
: Not less than 10 seconds
: If Rapid & Thready- Hypovolemia

77. Control of Haemorrage
 First- Direct Pressure to stop bleeding
 Put 2 large bore (16 gauze) canulla.
 Take Blood sample for grouping & Cross matching
 Infused 2 lit Warm R.L . Very Fast.
 Find out the cause of Bleeding: USG

78. FAST : USG in Trauma
 Focused Assessment Sonography in Trauma Patients
 4 quadrant has been examined.
 Right Hypochondrium – Hepatorenal Area
 Left Hypochondrium – Splenorenal Area
 Cardiac Window- To see the Heart: Cardiac Tamponade
 Suprapubic Region- Bladder Region

79. Disability :
 Rapid Neurological Examination –Performed
 Includes: The Patient’s Level of Consciousness, Pupillary
Size & Pupillary reaction.
 Best : GCS
 GCS: Comprises 3 component: Eye opening, Verbal
Response and Motor Response.
 GCS: Predictor for pt”s outcome particularly the Best
Motor Response.

80. GCS: Eye Opening
Response Score
Eye Opening Spontaneously 4
Eye opening on Verbal Response 3
Eye opening on Painful Stimuli 2
Eye opening - None 1

81. Verbal Response
Response Score
Fully Conscious 5
Confused 4
Inappropriate words 3
Incomprehensive words 2
None 1

82. Motor Response: Best Predictor
Response Score
Obeys Commands 6
Localize the Pain 5
Withdrawal( Normal Flexion) 4
Abnormal Flexion( Decorticate) 3
Extension( Decerebrate) 2
None 1

83. GCS
 Total Score(EVM) is 15, Minimum is 3
 Predictor to decide the prognosis:
 Motor Response is the Best to decide outcome:
 If GCS is less than 8 – Go for definitive airway i.e
Intubation
 If GCS : 12-15 ( Mild), 9-12( Moderate), 3-8( Severe) Head
Injury.

84. Exposure/ Environments
 Completely Undress the Patients by cutting off
his/her garments.
 Purpose: To Facilitate a through examination &
assessment.
 Prevent from Hypothermia: Cover with Warm Blanket
 Give only Warm IV Fluid.

86. PREVENTION/SOLUTION
 Follow the TRAFFIC RULE( Speed limit,Helmet wearing
Avoid drinking while driving, stop talking on mobile, donot
overtake,apply safety belt, avoid triple loading on bike etc.
 Empowered citizen.
 Save TIME=Save LIFE.
 Assessment ,Treatment as well Transport-Simultaneously.

87. Home Message
 RTA- Big issue for developing country like India
 Max death is due to ignorance of Pre-Hospital Care.
 Airway with C-spine protection is 1st step of primary survey
 Scene Safety is the first priority & assessment is the next.
 Triage is the top priority in mass casuality

88. Home message
 Helmet & Foreign Body removal , Jaw Thrust/Chin Lift
maneuver , Cervical collar application – can be done easily at
scene site.
 In Advanced setting – May proceed for Airway & ET Intubation
 Time is critical in trauma so only AMPLE history is required.
 Hypothermia should be prevented to break the triad of death.
 Chest tube is the TOC in most of chest trauma

89. Home Message
 Hemorrhage is the commonest cause of death in trauma
 In BTA- Spleen is the MC organ injured
 Direct Pressure is the first steps to stop any bleeding.
 FAST is very useful in detecting intra-abdomial bleed
 GCS: Best prognostic indicator in HI Patients

90. Thank You &