How to manage trauma patient in ER, a surgical resident role.

1. TRAUMA PATIENT
MANAGEMENT (IN FIRST 24 HOURS)
FROM A 1ST YEAR SURGERY RESIDENT POINT OF VIEW

2. ABOUT
TRAUMA
 Leading cause of death in the1 – 45-year-old
age group.
 Fourth cause of death in general population.
 10% of deaths.
 Most common and serious complications:
Hemorrhage.
 Blood loss → Decreased oxygen to tissues →
Hypoxemia → metabolic alterations →
(Lethal Triad).

3. WHAT HAPPENS IN POLY-TRAUMA
PATIENTS
 The defense mechanisms are activated by
• Hypoxia
• Acidosis
• Tissue hypoperfusion.
- Especially in the liver, kidney & lung.
 Which will triger a hyper-inflammatory
response
• Tachycardia (>90 bpm)
• Tachypnea (>20 breath pm)
• Body temperature >38.5 °C
• Leukocytosis
 The clinical consequences
• ARDS
• MOFS

4. THE INITIAL MANAGEMENT OF
THE POLY-TRAUMA PATIENT
 Prehospital trauma life support (PHTLS)
• Triage.
• Immediate life support.
• Information and communication.
 Advanced trauma life support (ATLS)
• Primary Survey (A,B,C,D,E)
• Secondary Survey.
• Definitive treatment of injuries.

5. ADVANCED TRAUMA LIFE SUPPORT (ATLS)
A,B,C,D,E
 A (Airway)
 B (Breathing)
 Tension Pneumothorax
 Flail Chest
 Open Pneumothorax
 Massive Hemothorax
 C (Circulation)
 External Hemorrhage
 Internal or hidden
hemorrhage
 D (Disability)
 GCS Scale
 E (Exposure)

6. SECONDARY SURVEY
OF POLY-TRAUMA PATIENT
Mnemonic Secondary survey
Has Head/skull
My Maxillofacial
Critical Cervical Spine
Care Chest
Assessed Abdomen
Patient's Pelvis
Priorities Perineum
Or Orifices (PR/PV)*
Next Neurological
Management Musculoskeletal
Decision? Diagnostic tests/
definitive care
Secondary survey mnemonic
*Tubes and fingers in every orifice. Include “AMPLE” history.

7. PHYSICAL EXAMINATION
OF POLY-TRAUMA PATIENT
 Head
 For neurologic injuries
 Scalp
 Eyes
 Maxillofacial Structures
 Intraoral examination
 Palpate bony structures
 Assess Soft tissues
 Cervical Spine & Neck
 Chest
 Inspection, palpation, auscultation and percussion + CXRay (A-P)
 Palpate entire chest cage + Clavicles, ribs and sternum.
 Abdomen & Pelvis
 Diagnostic peritoneal lavage especially in Unexplained hypotension.
 Abdominal - Pelvic US / CT
 Ecchymosis over iliac wings, pubis, labia, or scrotum
 Pain on palpation of pelvic ring.
 Assess peripheral pulses for vascular lesions.
 Perineum, rectum and Vagina

8. POLY TRAUMA
PATIENT
 Road traffic accident (RTA).
 Falling from height (FFT).
 Falling to the ground (FTG).
 Blunt trauma.
 Penetrating trauma.

9. HOW TO MANAGE
POLY-TRAUMA PATIENT PRESENTED TO ER

10. COMATOSE
TRAUMA PATIENT
 This patient should be rushed & managed in the recovery room in the presence of emergency medicine
doctor.
 1st: Airway / Foreign body.
 2nd: Pulse, blood pressure and respiratory rate.
 3rd: Good exposure of the patient. (for external bleeding or contusions)
 4th: Abdomen, chest and head examination.
 5th: 2 Wide bore cannulas + fluids (ringer for example)
 6th: Urinary Catheter.
 7th: Lab investigations (CBC, ABG, INR and blood cross match)
 8th: If these steps were established, you should accompany the patient for CXR and FAST.
 9th: Call your Senior with 13 Items (Age – Medical Hx – Mode of Trauma – Time of Trauma – Pulse – BP –
RR – UOP – CBC – Abdominal examination – Chest examination – FAST – CXR).

11. CONSCIOUS
TRAUMA PATIENT
 1st: Check Pulse, blood pressure and respiratory rate.
 2nd: History taking: (Age, Medical history, time of trauma & mode of trauma)
 3rd: Check If Pulse is normal (from 60 to 100 BPM)
 4th: Check If Respiratory rate is normal (from 12 to 25 breath per minute)
 So Lab investigations (CBC & INR).
 5th: Good exposure for the patient. & Check for external bleeding (cut wound, penetrating wound,
bruises, contusions) If you found any bleeding, dressing and compression should be done.
 7th: Check Abdomen, Chest and Head.
 8th: If Patient Pulse/RR/BP is abnormal, apply two wide bore cannulas, fluids and a urinary catheter and
move with the patient to CXR and FAST.
 9th: Call your Senior with 13 Items (Age – Medical Hx – Mode of Trauma – Time of Trauma – Pulse – BP –
RR – UOP – CBC – Abdominal examination – Chest examination – FAST – CXR).

12. DR. ALSAYED TAREK DAWABA
GENERAL SURGERY RESIDENT, MSH, EGYPT