This document discusses the management of trauma patients. It begins by defining trauma and listing common causes. It then outlines the epidemiology of trauma, noting it is a leading cause of death ages 1-44 and mortality depends on economic factors. The document then prioritizes injuries as highest to lowest priority. It dedicates several sections to pre-hospital and hospital management of trauma patients, emphasizing assessment, resuscitation, and stabilization according to ATLS protocols. Unique challenges in elderly trauma patients are also reviewed. The document concludes by listing its three references.

2. Prepared by: Dr.Sayed Abdul Qahir
PGR2, Orthopedic surgery
MRH, Kandahar, Afghanistan
Supervisor: Dr. Niamatullah shehzad
Trainer specialist, Orthopedic surgery
MRH, Kandahar, Afghanistan

3. Introduction and
epidemiology

4. Trauma(2)
 Trauma is an event, either witnessed or
experienced that represent a fundamental
threat to an individual’s physical safety or
survival
 Types of trauma could be:
1. RTA, MVA
2. Domestic
3. Sports
4. Occupational
5. Industrial
6. War
7. Natural disaster
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5. Epidemiology(1)
 It’s the commonest cause of death in
people from 1-44 years
 Mortality rate of major trauma is
dependent on different factors among
which economy is the biggest
high income nations is 35,middle
income is 55 and low income nations is
63 percent
 Deaths as a result of trauma follows a
tri-model pattern
50% immediately from non-survivable
injuries(CNS,CVS)
30% die within 1-3 hours
20% die from complications during 6
weeks after injuries(sepsis, multi-failure)
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6. Priority(2)
*Highest priority:
 Cervical spine injury
 Respiratory impairment
 Cardiovascular insufficiency
 Severe external hemorrhage
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*Priorities in management of trauma victims 192-195

7. Priority(2)
High priority:
 Intraperitoneal injuries
 Retroperitoneal injuries
 Brain and spinal cord injuries
 Severe burns or extensive soft tissue
injuries
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8. Priority(2)
Low priority:
 Lower genito-urinary tract injuries
 Peripheral vascular, nerve and tendon
injuries
 Fractures and dislocations
 Facial and soft tissue injuries
 Tetanus prophylaxis
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9. Management

10. Pre hospital management(1)
 Organization(BASICS,SAMU)
 Safety on scene
 Immediate action and triage
 Assessment and initial management
 Extrication and immobilization
 Transfer to hospital
 Air ambulances
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11. Pre hospital management(1,3)
Immediate action and triage:
 Triage sieve and triage sort
They both place causality into:
Priority 1 Immediate
Priority 2 Urgent
Priority 3 Delayed
Priority 4 Dead
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12. Pre hospital management(1)
Assessment and management:
 1. Awareness
 2. Recognition
 3. Management
Airway
Breathing
Circulation
Disability
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13. Pre hospital management(1)
 Extrication and immobilization
 Transfer to hospital
 Air ambulances(hospital emergency
medical services HEMS)
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14. Hospital management(1)
 1. Organization
The right pt to the right hospital in the right time
 2. Trauma teams
 3. Assessment and management(ATLS)
 4. Initial Assessment
 5. Systemic management
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15. Hospital management(1)
2. Trauma teams:
 First-tier response
Emergency department physician
Anesthetist
Emergency department nurse
Radiographer
 Second tier response
Surgeon from appropriate specialty
intensive care specialist
specific specialist(eg. ENT or EYE)
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16. Hospital management
3. Assessment and management(ATLS)(1,3)
 This system is based on three stages approaches:
1. Primary survey and simultaneous resuscitation
2. Secondary survey
3. Definitive care
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James styner 1976

17. Hospital management
4. Initial management(1)
 Airway with c-spine protection
 Breathing/ventilation/oxygenation
 Circulation with hemorrhage control
 Disability/neurological status
 Expose/ Environment/ keep warm
Triage within the ATLS system
Airway: Actual or impending obstruction
Priority 1
Breathing: Hypoxia or ventilatory failure
Priority 2
Circulation: External hemorrhage or shock
Priority 3
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18. Hospital management
4.1 Primary survey(1)
Airway:
 Establish patent airway and protect c-
spine
Pitfalls:
 Occult airway injury
 Equipment failure
 Inability to intubate
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19. Hospital management
4.1 Primary survey(1)
Breathing:
 Respiratory rate
 Chest movement
 Air entry
 Oxygen saturation
 Look, feel, palpate and listen for:
tension pneumothorax
open pneumothorax
severe flail chest
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20. Hospital management
4.1 Primary survey(1)
Tension pneumothorax:
One way valve air leak
 Dyspnea and tachypnea
 Distended neck vein
 Deviated trachea
 Hypotension
 Tympanic on percussion
 Absent breath sound
Rx: Immediate needle thoracotomy/ICD
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Open pneumothorax:
• Abnormal connection between
pleural cavity and atmosphere
causing inability to ventilate the lungs
• Rx: Three sided
dressing/ICD/Oxygenation

21. 21

22. Hospital management
4.1 Primary survey(1)
Severe flail chest:
 If 2 or more ribs fractured in 2 or more
places
 Dyspnea and tachypnea
 Paradoxical movement
 Decreased breath sound
Rx: Intubation/oxygenation/pain
control/chest physio
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23. Hospital management
4.1 Primary survey(1,3)
Circulation:
 Control of hemorrhage
stop external bleeding
find source of shock
(massive hemothorax, cardiac
tamponade, massive hemorrhage)
 Restore volume
 Reassess patient
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24. Hospital management
4.1 Primary survey(1)
Massive hemothorax:
 Rapid accumulation of more than 1500
ml of blood in the chest cavity
 Systemic/pulmonary vessel disruption
 Flat vs distended neck veins
 Shock with no breath sound and/or
percussion dullness
 Rx: ICD/ IV Fluid Infused 2 lit warmed
RL very fast/ Blood Transfusion at
earliest/Thoracotomy
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25. Hospital management
4.1 Primary survey(1)
Cardiac temponade:
 Accumulation of fluid or blood in
pericardial space
 Beck’s triad:
Hypotension
Distant heart sound
Engorged neck vein
 Pericardiocentesis
 thoracotomy
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26. Hospital management
4.1 Primary survey(1)
Fluid resuscitation:
 warm R/L 2L I/V in 15 mins or 20ml/kg in children
Rapid responders: Lost < 20 per cent blood volume. No further fluid is required
Transient responders: Lost 20–40% blood volume. These patients will need
further fluid administration and blood transfusion
Non-responders: Immediate transfusion and surgery to stop any hemorrhage.
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27. Hospital management
4.1 Primary survey(1)
Disability:
 Baseline neurologic evaluation
GCS
Pupillary response
Exposure/Environment:
 Completely undress the patient
 Be careful to prevent hypothermia
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28. Pre hospital management(3)
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29. Hospital management
4.2 Adjunct to Primary survey(1)
 Vital signs, ECG, Pulse oximetry
 ABGs
 Urine output
 Foley's, N/G
 CXR, pelvic Xray
 FAST or DPL
 Re-evaluation
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30. Hospital management
4.3 secondary survey(1)
 WHEN DO I START THE SECONDAR
Y SURVEY?
Primary survey is completed
ABCDES are reassessed
Vital functions are returning to nor
mal
 History (AMPLE)
* Allergies
* Medications
* Past illnesses, Personal history,
Pregnancy
* Last meal
* Events/Environment/ Mechanism
 Physical examination *
Head
* Maxillofacial
* C-spine and neck
* Chest
* Abdomen
* Pelvis and perineum
* Extremities
* Neurological function
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31. Hospital management
4.4 Adjunct to secondary survey(1)
 Monitoring: Vital signs, ECG, pulse, o2
Catheters: NG, Foley’s
Investigations: CXR, Pelvic Xray,
ABGs
Re-evaluation!!
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32. UNIQUE PROBLEMS(1)
AIRWAY:
 Dentition (including dentures)
 Nasopharyngeal mucosal fragility
 Cervical arthritis
BREATHING:
 Use of supplemental oxygen
 COPD
 Chest injuries poorly tolerated
CIRCULATORY:
 Decreased cardiovascular function
 Cautious fluid administration
Increased BP, decreased HR, and loss
of renal function with age
 Anticoagulants and other medications
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33. UNIQUE PROBLEMS(1)
NEUROLOGIC:
 Acute and chronic subdural
hematomas
 Altered sensorium secondary to
cerebral atrophy, hypoperfusion, and
medications
 Spinal osteoarthritis, leading to
frequent spinal column and cord
injuries
EXPOSURE:
 Abnormal thermoregulatory mechanism
 Increased sensitivity to hypothermia
 Increased risk of infection
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34. Hospital management(1)
 4.5 Transfer
 4.6 Definitive care
 5. systemic management
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35. References
 1. Apley’s system of orthopedics and fractures, Louis Solomon, 9th edition
 2. Orthopedic Emergencies, Melvin C. and Eric C. Makhni,
Second Edition
 3. John Ebnezar Textbook of Orthopedics,4th edition
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