APPROACH TO TRAUMAAPPROACH TO TRAUMAInitial Assessment and ManagementInitial Assessment and ManagementDR AMER BHUTTAK E M ULAHORE
ObjectivesObjectives Demonstrate concepts ofDemonstrate concepts ofprimary and secondary patientprimary and secondary patientassessmentassessment Establish managementEstablish managementpriorities in trauma situationspriorities in trauma situations Initiate primary and secondaryInitiate primary and secondarymanagement as necessarymanagement as necessary Arrange appropriateArrange appropriatedispositiondisposition
TraumaTrauma 180,000 people die each year180,000 people die each year (USA)(USA) 580,000people each yearworld580,000people each yearworld 1 person every 3 minutes.USA1 person every 3 minutes.USA 9 person every minutes..9 person every minutes.. leading cause of death ages 1–44.leading cause of death ages 1–44. Injury is a majoreconomic burden to societies cost more than $406-500 billion annuallycost more than $406-500 billion annually
Motorvehicle accidents responsible for80% ofMotorvehicle accidents responsible for80% of(blunt) trauma &50% deaths.(blunt) trauma &50% deaths.ROAD TRAFFIC INJURIESAn estimated 3,500 people are killed each day, including 1,000children, around the world in road traffic crashes involving cars,buses, motorcycles, bicycles, trucks, or pedestrians.Annually, 1.3 million are killed and at least 50 million are injuredeach year from traffic injuries—a number likely to double by 2020.
Deathsfollowing TraumaDeathsfollowing Trauma Trimodal distributionTrimodal distributionminuteshourgolden daysweekslethalinjuriesApnea, sever brain injury,high spinal cord , ruptureheart, major vessel, aorta,life threateninginjuriescomplications(sepsis, MOF)
Concepts of trauma managementConcepts of trauma management Treat thegreatest threat to lifefirstTreat thegreatest threat to lifefirst Thelack of adefinitivediagnosisshouldThelack of adefinitivediagnosisshouldnever impedetheapplication of annever impedetheapplication of anindicated treatmentindicated treatment A detailed history isnot essential tobegin theevaluation “ABCDE” approach
Pre-hospital triageTriage is the process of grouping injuryvictims according to risk of death or otheradverse outcome.Pre hospital care providers can be trainedto carry out this process according to apredetermined checklist of criteria or asystem of injury severity scoring.
Pre-hospital triage This triage of trauma patients usually depends onthree simple groups of factors: Physiology: the vital signs (e.g. pulse >120/min,systolic blood pressure <90 mmHg, GlasgowComa Scale score [GCS] <15) Anatomy: the immediately evident injuries (e.g.fractured long bones, spinal cord injury,penetrating injury) Mechanism of injury: e.g. fall >5 m, injury totwo or more body regions, vehicle crash withejection
Primary SurveyPrimary SurveyPatientsareassessed andPatientsareassessed andtreatment prioritiestreatment prioritiesestablished based on theirestablished based on theirinjuries, vital signs, andinjuries, vital signs, andinjury mechanismsinjury mechanisms
Initial Assessment and ManagementInitial Assessment and Management ABCDEs of trauma careABCDEs of trauma care–AA Airway and c-spine protectionAirway and c-spine protection–BB Breathing and ventilationBreathing and ventilation–CC Circulation with hemorrhageCirculation with hemorrhagecontrolcontrol–DD Disability/Neurologic statusDisability/Neurologic status–EE Exposure/Environmental controlExposure/Environmental control
AirwayAirwayHow do we evaluate the airway?How do we evaluate the airway?Airway compromise is likelyAirway compromise is likelyMaxillofacial traumaMaxillofacial traumaNeck traumaNeck traumaLaryngeal traumaLaryngeal traumaAirway obstructionAirway obstruction
A- AirwayA- AirwayAirway should be assessed forAirway should be assessed forpatencypatency– Is the patient able to communicate verbally?Is the patient able to communicate verbally?– AgitationAgitation– Inspect for any foreign bodiesInspect for any foreign bodies– Examine for stridor, hoarseness, gurgling,Examine for stridor, hoarseness, gurgling,pooledpooled secrecretion or bloodsecrecretion or blood–Pulse oximetryPulse oximetry
Assume c-spine injury in patients withAssume c-spine injury in patients withblunt multisystem traumablunt multisystem trauma– C-spine clearance is both clinical andC-spine clearance is both clinical andradiographicradiographic– C-collar should remain in place until patientC-collar should remain in place until patientcan cooperate with clinical exacan cooperate with clinical examm– Patient, head and neck should not bePatient, head and neck should not be– Hyperextended, hyper flexed or rotated;;;;;Hyperextended, hyper flexed or rotated;;;;;
Airway InterventionsAirway InterventionsSupplemental oxygenSupplemental oxygenSuctionSuction Chin lift/jaw thrustChin lift/jaw thrust Oral/nasal airwaysOral/nasal airways Definitive airwaysDefinitive airways– RSI for agitated patients with c-spine immobilizationRSI for agitated patients with c-spine immobilization– ETI for comatose patients (GCS<8)ETI for comatose patients (GCS<8)
Cervical Spine ProtectionCervical Spine Protection High index of suspicion depending on theHigh index of suspicion depending on thehistory of the accident: (traffic accidents, falls,history of the accident: (traffic accidents, falls,certain sports).certain sports). Avoid rough manipulation of the head andAvoid rough manipulation of the head andneck. Use hard collars to immobilize the neck.neck. Use hard collars to immobilize the neck.Immobilize the whole body on a long spinalImmobilize the whole body on a long spinalboard.board.
BreathingBreathing What can we look for clinically to assess aWhat can we look for clinically to assess apatient’s ‘breathing’ status?patient’s ‘breathing’ status?
B- BreathingB- Breathing Airway patency alone does not ensure adequateAirway patency alone does not ensure adequateventilationventilation Inspect, palpate, and auscultateInspect, palpate, and auscultate– Deviated trachea, crepitus, flail chest,Deviated trachea, crepitus, flail chest,sucking chest wound, absence of breathsucking chest wound, absence of breathsoundssounds CXR to evaluate lung fieldsCXR to evaluate lung fields
Chest TraumaChest TraumaThe Primary Killers Of Acute TraumaThe Primary Killers Of Acute TraumaPatientsPatients1.1.HypoxiaHypoxia2.2.hypoventilationhypoventilation
What would we do for this patient who is havingWhat would we do for this patient who is havingdifficulty breathing?difficulty breathing?X.RAYX.RAY
HemothoraxHemothorax COLLECTION OF BLOOD IN THECOLLECTION OF BLOOD IN THEPLEURAL SPACEPLEURAL SPACE CAUSED BY BLUNT ORCAUSED BY BLUNT ORPENETRATING TRAUMA.PENETRATING TRAUMA. MOST HAEMOTHORACES AREMOST HAEMOTHORACES ARETHE RESULT OFTHE RESULT OF RIB FRACTURES,RIB FRACTURES, LUNG PARENCHYMAL ANDLUNG PARENCHYMAL ANDMINOR VENOUS INJURIES, ANDMINOR VENOUS INJURIES, ANDAS SUCH ARE SELF-LIMITINGAS SUCH ARE SELF-LIMITING..
Flail SegmentFlail Segment•• 2 or more consecutive ribs broken in 2 or2 or more consecutive ribs broken in 2 ormore placesmore places•• Paradoxical movement of the flail segmentParadoxical movement of the flail segmentinterferes with thoracic volume and createsinterferes with thoracic volume and createspain/crepitus, forcing the pt to minimizepain/crepitus, forcing the pt to minimizevolumevolume•• Stabilize segment and assist ventilations ifStabilize segment and assist ventilations ifneededneeded
Breathing InterventionsBreathing Interventions Ventilatewith 100% oxygenVentilatewith 100% oxygen Needle decompression if tensionNeedle decompression if tensionpneumothorax suspectedpneumothorax suspected Chest tubes forpneumothorax /Chest tubes forpneumothorax /hemothoraxhemothorax Occlusive dressing to sucking chestOcclusive dressing to sucking chestwoundwound If intubated, evaluateETT positionIf intubated, evaluateETT position
C- CirculationC- Circulation Hemorrhagic shock should beassumed in anyHemorrhagic shock should beassumed in anyhypotensivetraumapatienthypotensivetraumapatient Rapid assessment of hemodynamic statusRapid assessment of hemodynamic status– Level of consciousnessLevel of consciousness– Skin colorSkin color– Pulsesin four extremitiesPulsesin four extremities– Blood pressureand pulsepressureBlood pressureand pulsepressure
Hemorrhage -four classesHemorrhage -four classes Class IClass I Hemorrhage involves up to 15% ofHemorrhage involves up to 15% ofblood volume.blood volume. There is typically no change in vitalThere is typically no change in vitalsigns and fluid resuscitation is notsigns and fluid resuscitation is notusually necessary.usually necessary.
Class IIClass II Hemorrhage involves 15-30% of total blood volume.Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) withA patient is often tachycardic (rapid heart beat) witha narrowing of the difference between the systolica narrowing of the difference between the systolicand diastolic blood pressures.and diastolic blood pressures. The body attempts to compensate with peripheralThe body attempts to compensate with peripheralvasoconstriction. Skin may start to look pale and bevasoconstriction. Skin may start to look pale and becool to the touch. The patient may exhibit slightcool to the touch. The patient may exhibit slightchanges in behavior.changes in behavior. Volume resuscitation with crystalloids (SalineVolume resuscitation with crystalloids (Salinesolution or Lactated Ringers solution) is all that issolution or Lactated Ringers solution) is all that istypically required.typically required. Blood transfusion is not typically required.Blood transfusion is not typically required.
Hemorrhage -four classesHemorrhage -four classes Class IIIClass III HemorrhageHemorrhageinvolves loss of 30-40% of circulating bloodinvolves loss of 30-40% of circulating bloodvolume.volume.blood pressure drops, the heart rate increases,blood pressure drops, the heart rate increases,peripheral perfusion (shock), such as capillary refillperipheral perfusion (shock), such as capillary refillworsens, and the mental status worsens.worsens, and the mental status worsens.Fluid resuscitation with crystalloid and bloodFluid resuscitation with crystalloid and bloodtransfusion are usually necessary.transfusion are usually necessary. Class IVClass IV Hemorrhage involves loss of >40% of circulatingHemorrhage involves loss of >40% of circulatingblood volume. The limit of the bodys compensation isblood volume. The limit of the bodys compensation isreached and aggressive resuscitation is required toreached and aggressive resuscitation is required toprevent death.prevent death.
Circulation InterventionsCirculation Interventions Cardiac monitorCardiac monitor Apply pressure to sites of external hemorrhageApply pressure to sites of external hemorrhage Establish IV accessEstablish IV access– 2 large bore IVs2 large bore IVs– Central lines if indicatedCentral lines if indicated Cardiac tamponade decompression if indicatedCardiac tamponade decompression if indicated Volume resuscitationVolume resuscitation– Have blood ready if neededHave blood ready if needed– Level One infusers availableLevel One infusers available– Foley catheterto monitorresuscitationFoley catheterto monitorresuscitation
Hemorrhagic shockHemorrhagic shock RAPID HEMOSTASISRAPID HEMOSTASIS BALANCED RESUSCITATIONBALANCED RESUSCITATION CRYSTALLOIDSCRYSTALLOIDS BLOODBLOOD EARLY IDENTIFICATION ANDEARLY IDENTIFICATION ANDCONTROL OF A SOURCE OFCONTROL OF A SOURCE OFHEMORRAHAGE IS ESSENTIALHEMORRAHAGE IS ESSENTIAL
D- DisabilityD- Disability Abbreviated neurological examAbbreviated neurological exam– Level of consciousnessLevel of consciousness– Pupil size and reactivityPupil size and reactivity– Motor functionMotor function– GCSGCS» Utilized to determine severity of injuryUtilized to determine severity of injury» Guide for urgency of head CT and ICPGuide for urgency of head CT and ICPmonitoringmonitoring
Disability InterventionsDisability Interventions Spinal cord injurySpinal cord injury– High dose steroids if within 8 hoursHigh dose steroids if within 8 hours ICP monitor- Neurosurgical consultationICP monitor- Neurosurgical consultation Elevated ICPElevated ICP– Head of bed elevatedHead of bed elevated– MannitolMannitol– HyperventilationHyperventilation– Emergent decompressionEmergent decompression
E- ExposureE- Exposure Complete disrobing of patientComplete disrobing of patient Logroll to inspect backLogroll to inspect back Rectal temperatureRectal temperature Warm blankets/external warming device toWarm blankets/external warming device toprevent hypothermiaprevent hypothermia
Always Inspect the BackAlways Inspect the Back
Secondary SurveySecondary Survey AMPLE historyAMPLE history– Allergies, medications, PMH, last meal, eventsAllergies, medications, PMH, last meal, events Physical exam from head to toe, includingPhysical exam from head to toe, includingrectal examrectal exam Frequent reassessment of vitalsFrequent reassessment of vitals Diagnostic studies at this timeDiagnostic studies at this timesimultaneouslysimultaneously– X-rays, lab work, CT orders if indicatedX-rays, lab work, CT orders if indicated– FAST examFAST exam
Diagnostic AidsDiagnostic Aids Standard trauma labsStandard trauma labs– CBC, K, Cr, PTT, Utox, EtOH, ABGCBC, K, Cr, PTT, Utox, EtOH, ABG Standard trauma radiographsStandard trauma radiographs– CXR, pelvis, lateral C-spine (traditionalCXR, pelvis, lateral C-spine (traditionally)ly) CT/FAST scansCT/FAST scans Pt must be monitored in radiologyPt must be monitored in radiology Pt should only go to radiology if stablePt should only go to radiology if stable
Tension PneumothoraxTension PneumothoraxHow do you treat this?How do you treat this?
HemothoraxHemothoraxIs this patient lying or upright?Is this patient lying or upright?
Widened MediastinumWidened MediastinumWhat disease process does this indicate?What disease process does this indicate?
Bilateral Pubic Ramus Fractures andBilateral Pubic Ramus Fractures andSacroiliac Joint DisruptionSacroiliac Joint DisruptionWhat should this injury make you worry about?What should this injury make you worry about?
Subdural Hematoma with SAHSubdural Hematoma with SAH
FAST ExamFAST Exam Focused Abdominal Scanning in TraumaFocused Abdominal Scanning in Trauma 4 views: Cardiac, RUQ, LUQ, suprapubic4 views: Cardiac, RUQ, LUQ, suprapubic Goal: evaluate for free fluidGoal: evaluate for free fluidSee normalLiver and kidneyFree fluid in MorrisonsPouch between liver andkidney
The Nature Of Maxillofacial TraumaThe Nature Of Maxillofacial TraumaThere are a number of possible causes of facial traumaThere are a number of possible causes of facial traumasuch as motor vehicle accidents, dog bites, accidentalsuch as motor vehicle accidents, dog bites, accidentalfalls, sports injuries, interpersonal violence, and work-falls, sports injuries, interpersonal violence, and work-related injuries.related injuries.Types of facial injuries can range from injuries ofTypes of facial injuries can range from injuries ofteeth to extremely severe injuries of the skin and bonesteeth to extremely severe injuries of the skin and bonesof the face.of the face.Typically, facial injuries are classified as either softTypically, facial injuries are classified as either softtissue injuries (skin and gums), bone injuriestissue injuries (skin and gums), bone injuries(fractures), or injuries to special regions (such as the(fractures), or injuries to special regions (such as theeyes, facial nerves or the salivary glands).eyes, facial nerves or the salivary glands).
MAXILLOFACIAL TRAUMAMAXILLOFACIAL TRAUMA Facial injuries have the potential to cause facial disfigurement andFacial injuries have the potential to cause facial disfigurement andloss of function; for example, blindness or difficulty moving the jawloss of function; for example, blindness or difficulty moving the jawcan result.can result. Although it is seldom life-threatening, facialAlthough it is seldom life-threatening, facialtrauma has the potential to be fatal as it can causetrauma has the potential to be fatal as it can causesevere bleeding or interference with the airway;severe bleeding or interference with the airway;thus a primary concern in treatment is ensuring thatthus a primary concern in treatment is ensuring thatthe airway is kept open and not threatened so thatthe airway is kept open and not threatened so thatthe patient can breathe.the patient can breathe.
SummarySummary Trauma is best managed by a teamTrauma is best managed by a teamapproach (there’s no “I” in trauma)approach (there’s no “I” in trauma) A thorough primary and secondary surveyA thorough primary and secondary surveyis key to identify life threatening injuriesis key to identify life threatening injuries Once a life threatening injury is discovered,Once a life threatening injury is discovered,intervention should not be delayedintervention should not be delayed Disposition is determined by the patient’sDisposition is determined by the patient’scondition as well as available resources.condition as well as available resources.
Abdominal TraumaAbdominal Trauma Common source of traumatic injuryCommon source of traumatic injury Mechanism is importantMechanism is important– Bike accident over the handlebarsBike accident over the handlebars– MVC with steering wheel traumaMVC with steering wheel trauma High suspicion with tachycardia,High suspicion with tachycardia,hypotension, and abdominal tendernesshypotension, and abdominal tenderness Can be asymptomatic early onCan be asymptomatic early on FAST exam can be early screening toolFAST exam can be early screening toolHemorrhagic shock V
Abdominal TraumaAbdominal Trauma Look for distension, tenderness, seatbeltLook for distension, tenderness, seatbeltmarks, penetrating trauma, retroperitonealmarks, penetrating trauma, retroperitonealecchymosisecchymosis Be suspicious of free fluid without evidence ofBe suspicious of free fluid without evidence ofsolid organ injurysolid organ injury
Splenic InjurySplenic Injury Most commonly injured organ in blunt traumaMost commonly injured organ in blunt trauma Often associated with other injuriesOften associated with other injuries Left lower rib pain may be indicativeLeft lower rib pain may be indicative Often can be managed non-operativelyOften can be managed non-operativelySpleen withsurroundingbloodBlood fromspleenTracking aroundliver
Liver injuryLiver injury Second most common solid organ injurySecond most common solid organ injury Can bedifficult to managesurgicallyCan bedifficult to managesurgically Often associated with other abdominal injuriesOften associated with other abdominal injuriesLiver contusions
What’s wrong with this picture?What’s wrong with this picture? May only see the nasogastric tube appear to be coiledMay only see the nasogastric tube appear to be coiledin the lung.in the lung. Left > right due to liver protection of the diaphragm.Left > right due to liver protection of the diaphragm.Trace the DiaphragmOutline. Where is theDiaphragm on the left?Abdominal contentsUp in the chest on theleft
Hollow Viscous InjuryHollow Viscous Injury Injury can involve stomach, bowel, orInjury can involve stomach, bowel, ormesenterymesentery Symptoms are a result from a combination ofSymptoms are a result from a combination ofblood loss and peritoneal contaminationblood loss and peritoneal contamination Small bowel and colon injuries result mostSmall bowel and colon injuries result mostoften from penetrating traumaoften from penetrating trauma Deceleration injuries can result in bucket-Deceleration injuries can result in bucket-handle tears of mesenteryhandle tears of mesentery Free fluid without solid organ injury is aFree fluid without solid organ injury is ahollow viscus injury until proven otherwisehollow viscus injury until proven otherwise
Mesenteric and bowel injury from blunt abdominaltrauma. Notice the bowel and mesenteric disruption.bowelmesentery
CT Scan in TraumaCT Scan in Trauma Abdominal CT scan visualizes solid organsAbdominal CT scan visualizes solid organsand vessels welland vessels well CT does NOT see hollow viscus,CT does NOT see hollow viscus,duodenum, diaphram, or omentum wellduodenum, diaphram, or omentum well Some recent surgery literature advocatesSome recent surgery literature advocateswhole body scans on all traumawhole body scans on all trauma– Keep in mind that there is an increase inKeep in mind that there is an increase inmortality related to cancer from CT scansmortality related to cancer from CT scans
Non-accidental TraumaNon-accidental Trauma Key is SUSPICION!!!Key is SUSPICION!!! Incongruent stories of mechanismIncongruent stories of mechanism Delay in seeking treatmentDelay in seeking treatment Multiple stages of injuriesMultiple stages of injuries Pattern InjuriesPattern Injuries Multiple hospital visitsMultiple hospital visits Injury mechanism beyond the scope of the age ofInjury mechanism beyond the scope of the age ofchild (6week old rolled over off the bed)child (6week old rolled over off the bed) Bite marks, submersion injury, cigarette burnsBite marks, submersion injury, cigarette burns
Disposition of Trauma PatientsDisposition of Trauma Patients Dictated by the patient’s condition and availableDictated by the patient’s condition and availableresources i.e. trauma team availableresources i.e. trauma team available– OR, admit, or transferOR, admit, or transfer Transfers should be coordinated effortsTransfers should be coordinated efforts– Stabilization begun prior to transferStabilization begun prior to transfer– Decompensation should be anticipatedDecompensation should be anticipated Serial examinationsSerial examinations– CHI with regain of consciousnessCHI with regain of consciousness– Abdominal exams for documented blunt traumaAbdominal exams for documented blunt trauma– Pulmonary contusions with blunt chest traumaPulmonary contusions with blunt chest trauma
SourcesSources ATLS Student Course Manuel, 6ATLS Student Course Manuel, 6ththedition.edition. Rosen’s Emergency Medicine Concepts andRosen’s Emergency Medicine Concepts andClinical Practice, 5Clinical Practice, 5ththedition.edition. Emergency Medicine A ComprehensiveEmergency Medicine A ComprehensiveStudy Guide, 5Study Guide, 5ththedition.edition.