Management of trauma

1.
Help! Call Your Surgeon
1
James Cook University Hospital Middlesbrough,
United Kingdom
Reza Mofidi1

2. Lozano et al. Lancet 2012; 380: 2095–128

3. Lozano et al. Lancet 2012; 380: 2095–128

4. Trauma Systems of Care
 R Adams Cawley (1950s-1960s)
 Donald Trunkey (1970s-early 1980s)
 Golden Hour
 ATLS
 Specific training for surgeons
 Development of Trauma centres
 Multispecialty teams
 Concentrate experience
Cales RH, Trunkey DD. Preventable trauma deaths: a review of trauma care systems
development. JAMA 1985;254(8):1059-63.

6. Systems of care
 Injury prevention
 Pre-hospital care
 Triage / Management of multi trauma
 Resuscitation (protocolized care)
 Damage control surgery
 Definitive treatment
 Rehabilitation

7. Date of download: 8/10/2016
Copyright © 2016 American Medical
Association. All rights reserved.
From: The Effect of Organized Systems of Trauma Care on Motor Vehicle Crash Mortality
JAMA. 2000;283(15):1990-1994. doi:10.1001/jama.283.15.1990
Adjusted mortality rate ratios (MRRs) comparing mortality in states with a trauma system, according to years since system implementation, with expected mortality
based on mortality trends in all states. The dashed lines are pointwise 95% confidence bands. Estimates are adjusted for secular trends in crash mortality rates, traffic
safety laws, and changes in the age distribution of the population. Gray line indicates MRR equal to 1.
Figure Legend:

8. Husum H, Gilbert M, Wisborg T, et al. Journal of Trauma and Acute Care Surgery. 2003;54(6):1188-96.
Systems of Trauma care Cambodia and Northern Iraq

9. Husum H, Gilbert M, Wisborg T, et al. Journal of Trauma and Acute Care Surgery. 2003;54(6):1188-96.
Systems of Trauma care Cambodia and Northern Iraq

10. Husum H, Gilbert M, Wisborg T, et al. Journal of Trauma and Acute Care Surgery. 2003;54(6):1188-96.
Systems of Trauma care Cambodia and Northern Iraq

11. DeBakey ME. Military surgery in World War II. N Engl J Med. 1947:236:341-350.

19. Jansen JO, Thomas R, Loudon MA, Brooks A. BMJ. 2009;338:1436-40.

20. Jansen JO, Thomas R, Loudon MA, Brooks A. BMJ. 2009;338:1436-40.

21. Date of download: 8/11/2016
Copyright © 2016 American Medical
Association. All rights reserved.
From: Feasibility of Damage Control Surgery in the Management of Military Combat Casualties
Arch Surg. 2000;135(11):1323-1327. doi:10.1001/archsurg.135.11.1323

22. Date of download: 8/11/2016
Copyright © 2016 American Medical
Association. All rights reserved.
From: Feasibility of Damage Control Surgery in the Management of Military Combat Casualties
Arch Surg. 2000;135(11):1323-1327. doi:10.1001/archsurg.135.11.1323
The time between damage control surgery (DCS) ("fast surgery") and surgery for definitive repair might be as short as 30 minutes or
require several days depending on the response to resuscitation. DO2/.VO2 indicates oxygen delivery and consumption.
Figure Legend:

23. Date of download: 8/11/2016
Copyright © 2016 American Medical
Association. All rights reserved.
From: Feasibility of Damage Control Surgery in the Management of Military Combat Casualties
Arch Surg. 2000;135(11):1323-1327. doi:10.1001/archsurg.135.11.1323

24. Annals of Surgery Volume 253, Number 6, June 2011

27. Annals of Surgery Volume 253, Number 6, June 2011

28. Injury Severity Score (ISS) distribution
Explosion: white bar
Gunshot wound: black bar
*
*
Peleg et al. Ann Surg 2004;239: 311–318

29. Peleg et al. Ann Surg 2004;239: 311–318

30. Injury distribution
Peleg et al. Ann Surg 2004;239: 311–318
=240
=170

31. Vascular Trauma
Head and neck and Torso

32. Assessment
 Resuscitation
 Primary Survey
 Damage control
 Arrest Haemorrhage
 Restore Circulating volume
 Treat Coagulopathy / Hypothermia / Acidosis

38. Zones of Head and Neck
Zone I-Below cricoid
Zone II-Between cricoid and mandible
Zone III-Above mandible

43. Surgical Approach
 Zone-1: Access to Mediastinum
 Zone-2 : Standard Carotid exposure
 Zone-3: High carotid exposure:
 Division of Posterior belly of digastric
 Divide Veins that run with hypoglossal
 Divide Ansa Cervicalis
 Divide occipital branch of external carotid artery
 Sublux the temporo-mandibular joint

49. Blunt thoracic aortic injury
 80-90% die prior to hospital arrival
 Cxr: Normal in 44%
 Subtle abnormalities:
 Widened mediastinum,
 Left pleural effusion,
 Loss of aorto-pulmonary window,
 Depression of the left main stem bronchus,
 Deviation of the trachea to the right,
 Widening of the right paratracheal stripe

54. Abdominal Injuries
 Patient Has Multiple Injuries
 Shocked
 Cold
 Acidotic
 Coagulopathic
 Septic

55. Damage Control
 Arrest haemorrhage
 Debride
 Remove ongoing contamination
 Pack abdomen
 Avoid abdominal compartment syndrome

63. Vascular Extremity Trauma
Combined Vascular and Skeletal Injury

64. Introduction
 Combined vascular and skeletal injury
 Challenging combination
 Rare: 0.2% of all injuries1
 0.5%-1.7% of all fractures and dislocations2
 10 fold increase in amputation rates
 3 Fold increase in failed revascularisation rates

65. Assessment
 Resuscitation
 Primary Survey
 Damage control
 Arrest Haemorrhage
 Limb salvage

66. Hard Signs
 Observed pulsatile bleeding
 Arterial thrill by manual palpation
 Bruit over or near the artery by auscultation
 Signs of distal ischaemia
 Visible expanding haematoma

67. Soft Signs
 Significant haemorrhage on history
 Decreased pulse compared to contra-lateral side
 Bony injury
 Proximity penetrating wound
 Neurologic abnormality

68. Sloan K, Mofidi R, Nagy J, Flett MM, Chakraverty S. Vasc Endovascular Surg. 2009;43(3):286-90.

69. Sloan K, Mofidi R, Nagy J, Flett MM, Chakraverty S. Vasc Endovascular Surg. 2009;43(3):286-90.

71. S Suttie, R Mofidi, R Bhat, J Nagy. Injury 2009; 40(3): 49-50.

72. Hard Signs of Vascular Injury
Imaging Definitive skeletal repair
Stable fracture
Reduce # /dislocation and reassess
Control /
Thrombectomy / shunt
Treat fracture Definitive Vascular repair
Angiography if soft signs are present
Fasciotomy
+
+
+
-
-
-

73. Suttie SA, Mofidi R, Howd A, Griffiths GD. J Med Case Reports. 2008;2:259.

74. Suttie SA, Mofidi R, Howd A, Griffiths GD. J Med Case Reports. 2008;2:259.

75. Suttie SA, Mofidi R, Howd A, Griffiths GD. J Med Case Reports. 2008;2:259.

76. http://.www.Trauma.org

77. http://.www.Trauma.org

78. http://.www.Trauma.org

79. http://.www.Trauma.org

80. http://.www.Trauma.org

81. http://.www.Trauma.org

84. Limb Salvage scoring Systems
 Predictive Salvage Index (PSI) - HOWE 1987
 MESS Mangled Extremity Severity Score
 NISSSA Nerve Injury, Ischemia, Soft-Tissue, Skeletal Injury, Shock, Age
score
 Limb Salvage Index (LSI) - Russell 1991

85. Risk Factors for Limb Loss/ Severe Dysfunction
Patient
• Shock and life-threatening associated injuries
• Elderly with medical co-morbidity
Vascular
• Prolonged ischemia (> 6-12 hours)
• Below-knee arterial injury
Injury
• Neurotemesis 2 or more extremity nerves
• Extensive soft tissue loss
• Crush injury
• Multiple fractures
• Severe contamination
• Patient preference (cultural sensitivities)

86. Take Home Message
 Robust systems of trauma care save life
 Structural change:
 Pre hospital care
 Trauma centres
 Up to date processes
 ATLS
 Damage Control resuscitation
 Damage control surgery