Primary Care

1. PRIMARY CARE FOR TRAUMA
Presented byPresented by : Dr Mohammed Haneef

2. Contents
Introduction
Principals of management
Sequence of management
Primary Survey
Secondary Survey
Conclusion
2

3. Introduction
Maxillofacial trauma involves injury to the facial soft
tissue or its bony structure.
It is commonly associated with multiple system
injuries.
 The most common mechanisms of injury are blunt or
crush injuries caused by personal assault and motor
vehicle accidents .
These concomitant injuries include cranial, spinal
upper and lower body injuries
3

4.  Trauma is the leading cause of
death in children and young
adults. Its effects are protean,
affecting not only the victim but
also their relatives and society
as a whole.
 If basic principles of primary
care are applied immediately,
the contribution can benefit the
patient and enhance his chances
of survival.
4

5. The first priority in management of a
patient with trauma is obviously the
preservation of the life of the patient.
6

6. TWO OBJECTIVES OF MANAGEMENT
To save life
To restore function
7

7. Principles of Management (Triage System)
When a patient with severe traumatic injury is first seen, an
immediate general evaluation must be made to determine if
emergency treatment is necessary.
Treatment Priorities
I. Immediate Intervention (5% main category for reported
deaths)
- Maintainance of airway Required
- Poly Trauma Patients
- Cardiac Conditions like arrest
- Management of Shock and Bleeding
II. Treatment required urgently ( 10-15%)
- Intra – abdominal bleeding
- Head injuries
- Chest injuries
III. Treatment that can wait ( non urgent -80%)
Maxillofacial trauma
8

8. SEQUENCE OF MANAGEMMENT
Trauma (Road traffic accident fall etc.)
↓
Primary Survey -> ABCDE defines
the specific prioritized evaluations and
intervention that should be followed in all injured
patients
↓
Secondary Survey
After initial survey has been accomplished and the patient
has been stabilized
Involves more time – consuming tests and observations
Does not begin until primary survey is completed
9

10. Primary survey
For assesment of patients in systemic fashon
Establishment of treatment priorities based
on injuries, vital signs, and injury mechanism
Identification of life threatning conditions
and their management
Based on ATLS protocol.

11. PRIMARY SURVEY
A-Airway management with cervical spine stabilization
B-Breathing and ventilation
C-Circulation with haemorrhage control
D-Disability,neurological status
E-Exposure and prevention of hypothermia
10

12. “A” AIRWAY PATENCY MANAGEMENT
Maintenance of patency of airway must be given
priority consideration, since adequate oxygenation is
vital to life.
11

13. Clinical Signs & Symptoms of Respiratory
Distress (Obstructions)
Initially there will be restlessness, apprehension,
anxiety.
Tachypnoea, tachycardia, pallor.
Rapid, labored breathing (gasping for breath).
Rapid movement or fluttering of the alae of the
nose.
12

14. Crowing sound, strider, intercostals retraction.
Suprasternal indrawing of the tissues or
supraclavicular retraction
Decreasing ventilatory excursions, hypercarbia,
hypertension.
Progressive cyanosis (may be present with Hb
less than 5 gm.)
13

15. Causes of respiratory obstructions related to
maxillofacial injuries.
 Inhalation of blood clot, vomit, saliva, thick mucosa or
portions of teeth, bone and dentures
 Inability to protrude the tongue, because of the
posterior displacement of the anterior fragment of the
mandible (Bilateral parasymphysis mandibular
fracture)
 Occlusion of oropharynx by the soft palate after
retroposition of the maxilla (fractured maxilla)
14

16. 16
Systematic approach to airway
management
1. Initial assessment : Recognize airway obstruction
2. Perform airway maneuvers, clear the airway,
reposition of patient.
3. Use artificial airways, perform bag-valve-mask
ventilation.
4. Perform endotracheal intubation.
5. Surgical airway if unable to intubate.

17. Airway Management
Non –Surgical
 Positioning of the patient
 Oropharyngeal toilet
 Suctioning of Vomitus
 Anterior traction of the
tongue
 Immediate restoration of
the position of soft palate.
Surgical
 Tracheostomy
 Cricothyroidotomy
16

18. Non Surgical Treatment
1.Position of the Patient.
Semi-prone position- will maintain clear airway mainly by
allowin& CSF from the airway & preventing partially avulsed soft
tissue g drainage of blood, saliva of the lips or cheeks from
obstructing the airway.
17

19.  Supine position with head extended should be
deprecated especially in spinal injuries.
18

20. 2. Oropharyngeal Toilet
 All blood clot, saliva, thick mucus or foreign bodies etc.
should be cleared from the oral cavity and throat by digital
exploration or by using cotton swabs, if available.
 Fingers of one hand maintain
open mouth while fingers of
other hand sweep through oral
cavity removing any
foreign material
19

21. 3. Suction
If suction machine is available, then catheters should be
used to clear the nose, oral cavity and throat.
20

22. 4. Anterior Traction of the
Tongue
 Control the tongue by the proper positioning
of the patient; or the tongue can be pulled
out and it can be maintained in the forward
position by using tongue suture or towel clip
attached to the patient’s shirt collar.
21

23. 5. Immediate restoration of the position of
soft palate.
- It can be brought about by doing disimpaction of the maxillary
fracture.
- This is achieved by placing index and middle finger into the
mouth hooking behind the soft palate and thumb placed on the
alveolus in the incisor region.
- Head is stabilized by counter pressure with other hand over the
fore head.
- Strong anterior and downward traction will bring the maxilla in
normal position.
- Immediately 1 or 2 well lubricated nasopharyngeal tubes should
be inserted to maintain the airway
22

24. 6. Mouth to mouth breathing
 First ventilation cycle is comprised of
four quick, full ventilations of the
victim without allowing time for full
lung deflation between breaths.
 Effective artificial ventilation is noted
by expansion of chest of the victim.
 In normal adult minimal volume
should be 800 ml but need not
exceed 1200 ml. of air for adequate
ventilation
23

25.  Exhalation is a passive process.
- The rescuer removes his or her mouth from
that of the victim, takes in a breath of fresh air,
and watches the chest fall.
For Adults : At a rate of one every 5 seconds (12 per
minute)
In children One every 4 seconds (15 per minute)
In infants : One every 3 seconds (20 per minute).
24

26. Rescuer places fingers of one hand on bony anterior portion of
mandible;other hand is placed on forehead and rotates the
head back.
It stretches soft tissues of the neck,lifting the tongue off the
pharynx and opening the airway.
Head-tilt,chin-lift
26

27. 7. Endotracheal intubation
If the airway is compromised or its integrity is
deteriorating as a result of haematoma formation,
soft tissue swelling, or surgical emphysema.
Types
Oral & Transnasal
Cuffed & uncuffed
27

28. Criteria for intubation
Clinical
 Shortened speech
 Use of accessory muscles
 Subjective air hunger
 Change in mental status
 Poor inspiratory force
Laboratory
 PaO2/fiO2<250
 PaCO2>50mmHg
PH < 7.25
RR >35
breaths/min
28

29. INDICATION FOR TRACHEAL
INTUBATION(ATLS)
Need for airway protection
 Unconscious
 Severe maxillofacial fractures
 Risk for aspiration
 Bleeding
 Vomiting
 Risk for obstruction
 Neck hematoma
 Laryngeal, tracheal injury
 Stridor
Need for ventilation
 Apnea
 Inadequate respiratory
effort
 Tachypnea
 Hypoxia
 Hypercarbia
 Cyanosis
 Severe closed head injury with need for
hyperventilation
29

30.  In addition, two more indications are
A combative patient who exacerbate potential
injuries & who cannot safely be controlled by any
other means &
A patient who is likely to have airway or breathing
difficulties in the near future.
30

31. Contraindication
 Real contraindication to tracheal intubation is the
ability to adequately secure & maintain an airway by
less invasive means.
Relative contraindication
 Severe midface fractures associated with basilar skull
fractures, to the nasal route.
 Severe laryngeal trauma with tracheal separation-to
orotracheal intubation since placement may further
complicate the injury.
This rare injury treated with emergency
tracheostomy
31

32.  Fiberoptic techniques are generaly not successful if
there are notable airway secretions, bleeding , or
emesis.
 Apnea is absolute contraindication to nasal
intubation.
 Blind intubation in the setting of major upper
airway or neck injuries.
32

33. Orotracheal intubation
 Preparation
 Suction
 Airway.
 Laryngoscope.
 Tube.
 Equipments
33

34. 34
Airway management devices:
A - oropharyngeal (Guedel) airway;
B - nasopharyngeal airway;
C - endotracheal tube with inflated cuff;
D - laryngoscope;
E - Magill forceps

35. Letter A shows the wrong and letter B shows the
correct position of patient's head
35
Position of the patient

36. 36
Technique of direct laryngoscopy
and orotracheal intubation.
Curved blade placement in
orotracheal intubation.
Technique

37. Straight blade technique:
37

38. 38
Fiberoptic intubation Indications:
 Routine intubation, difficult
intubation, abnormal airway,
compromised airway
 Neck extension not desirable
 Assessment of tube placement
 Risk of dental damage
 Removal of secretions and mucus
plugs
 Contraindications:
 Lack of skill
 Inability to oxygenate patient
 Major bleeding in the airway
Benumof JL. Anesthesiology 75:1086, 1991.

39. 39
Surgical airway
Inability to intubate the trachea for any reason is
an indication for creation of a surgical airway
when less invasive methods have failed to restore
an adequate airway.

40. SURGICAL
Tracheostomy
 In greek it means creating a window in the anterior
wall of the trachea.
 Tracheotomy: an incision or cutting into the trachea
 It is definative management in upper airway
obstruction in maxillofacial injuries.
40

41. INDICATIONSMajor laryngeal trauma with concern that cricothyrotomy or
orotracheal intubation might result in retraction of trachea in to
mediastinum.
Inability to intubate or perform needle cricothyrotomy in a
pediatric patients i.e no airway option available.
 Any patient that is adequately stable, and who requires a surgical
airway that can be placed in a controlled fashion in the operating
room.
Laryngeal foreign body or pathology (e.g tumor) that prohibits
cricothyrotomy.
 Prolonged ventilation.
 Facilitation of management of cervical spine injuries or oncologic
resections of head and neck
41

42. Contraindication
 if the patient airway can be safely secured by other
means( rescue airway, RSI, needle or open
cricothyrotomy, etc)
 In an expanding hematoma.
42

43. Complications
Perioperative
Hemorrhage
Pneumothorax
Subcutaneous
emphysema
Esophageal injury
False passage
Aspiration
Post
operative
 Plugging of the tube
with secretion
 Hemorrhage
 Infection
 Tracheal stenosis
 Tracheoesophagal
fistula
 Vocal cord paralysis
43

44. Procedure
44

45. 45

46. 46 46

47. 47 47

48. C spine immobilisation
 Well fitting hard collar & backboards
 “sandbags”
48

49. 49
Cricothyrotomy
1.Needel cricothyrotomy
2. cricothyrotomy

50. 50
Indications
1. Maxillofacial trauma; obstruction of the airway from
massive facial trauma is the most common indication for
cricothyrotomy.
2. Oropharyngeal obstruction; edema secondary to
infection, allergic reaction, thermal and caustic injuries,
foreign body, and mass lesions ; when oral or nasal
intubation is not possible.
3. Conditions in which tracheal intubation from above is either
contraindicated or unsuccessful, such as with congenital
malformations, massive hemorrhage, persistent vomiting,
intermitting laryngospasm.

51. Contraindications
1. Age: in children below age 11.
2. Crush injury to larynx: result in laryngeal
separation
3. Preexisting laryngeal or tracheal pathology:
obstruction secondary to tumor or subglotic
stenosis might prevent the establishment of
functional airway
51

52.  Needle cricothyrotomy procedure.
(A) Positioning (assuming no
contraindications) to expose the
external anatomy (eg, laryngeal
prominence).
 (B) Locating the cricothyroid
membrane (palpation of the
cricothyroid membrane).
 (C) Needle puncture of the
cricothyroid membrane (anterior
and side views).
 (D) Seldinger (guidewire) technique
for cricothyrotomy (cutaway of side
view and side view)
52
Needle cricothyrotomy

53. Cricothyrotomy
 Palate thyroid cartilage-inferior to the mandible & hyoid
bone in the midline
 Cricoid cartilage – 2 to 3 cm inferior to the thyroid
cartilage.
 A horizontal incision 2cm long is placed through the skin
& subcutaneous tissue.
 The incision is made just superior to cricoid cartilage to
avoid the anastomosis of the superior thyroid & cricoid
arteries.
 A tracheostomy tube is placed.

54. 54

55. Complications
Perioperative
Improper tube placement
Hemorrage
Prolonged execution time
Pneumomediastinum
Subcutaneous emphysema
Thyroid gland injury
Esophageal injury
Cartilage fracture
Recurrent laryngeal nerve injury
Post operative
Dysphonia,hoarness
Subglotic stenosis
Infection
Hemorrage
Aspiration
Occlusion of tube
Persistent stoma
Vocal cord paralysis
55

56. ADVANTAGES OF CRICOTHYROTOMY
OVER TRACHEOSTOMY
 Faster than tracheostomy, generally less than
2 min.
 Easier to perform, with less instrumentation
required.
 Fewer surgical complications & less bleeding
 Does not require extension of the neck.
56

57. B: Breathing
 Once the patient airway has been established & the
breathing sustained, the patient should be placed on
supplemental oxygen.
 Oxygen can be administered to the patient via nasal
cannula, a face mask, or endotracheal tube.
 It should be given until PaO2 >60-70mmHg.
 If administered for prolonged period-oxygen toxicity
57

58. C:circulation
1. Hypovolemic shock
2. Control of bleeding
3. Fluid resuscitation
4. Blood product replacement.
58

59. Hypovolemic shock and
hemorrage
 Hemorrage is the most common cause of hypovolemia in the
multisystem injured patient.
 Physiologic response can be categorized based on percentage of blood
loss.
59

60. Classes of hemorrhage
CLASS I CLASS II CLASS III CLASS IV
Blood volume
loss
Up to 15% 15% to 30% 30-40% >40%
Adult blood
volume amount
<750 ml 750-1500ml 2000ml >2000ml
Need for blood
transfusion
No Generally no Almost always Yes
Tachycardia Minimal Present Marked Marked
Systolic
pressure
changes
None None Decreased Decreased
Diastolic None Decreased Decreased Decreased
Urinary output
changes
None Midly affected Significantly
decreased
Negligible urine
output60

61.  While the primary assessment is taking place, ATLS
dictates that a minimum of two large-bore(16 to 14 gauge)
intravenous catheters should be placed in case of fluid
resuscitation.
 When blood loss is mild (less than 15% of blood
volume), no volume resuscitation is necessary.
 With moderate to severe blood loss, the only effective
management of hypovolemia is volume resuscitation.
61

62.  In hypovolemic shock, a standard volume resuscitation
approach is to administer 2 liters of crystalloid fluid as
a bolus.
 If no response, then colloid fluids are added to the
regimen.
 Colloids are efficient plasma expanders.
 There is a 1:1 ratio of colloid replacement to blood
loss and a 3:1 ratio for crystalloid replacement.
62

63. Blood product replacement
 Blood transfusion is to increase the oxygen-carrying
capacity of the blood
 Indicated for hemoglobin less than 6 g/dL.
 In case of whole blood loss-early replacement with O-
negative blood can be given.
 Not more 4 units of O-type blood should be administered.
 A unit of FFP is given for every 5 units of blood to prevent
coagulation abnormalities.
63

64.  If the patient doesn't respond to initial fluid
resuscitation and/or blood transfusions,
measure CVP with a catheter or evaluation
of the neck veins may assist with
hypovolemic shock.
 Patient is placed in trendelenburg’s position
to empty the large capacitance or venous
side of the peripheral circulation back to
heart.
64

65. Control of bleeding
 Prompt control of post traumatic bleeding is a must.
 Initial digital compression should be given to control
the bleeding-firm & continuous.
 Compression dressings also can be used.
 Major vessels which are cut, should be clamped or
ligated.
 Soft tissue wounds which are deep and extensive should
be sutured immediately
 Firm pressure applied proximal to major arteries to control
bleeding.
65

66.  Deep wounds also can be packed with gauze
till definite measures are taken.
 Nasal bleeding can be stopped by using
ribbon gauze packing soaked in 1:1000
adrenaline. In some cases post nasal packing
may be necessary
66

67. Method of insertion of a postnasal
pack  A flexible aspiration catheter 3mm in
diameter is passed via one nasal
aperture and retrieved with Magill
forceps from the oropharynx and it is
lead out through the mouth.
 A pack of about 4cm in diameter is
made and is tied with tape.Two ends are
left,one of each is passed into the end of
catheter which is then withdrawn back
through the nose.
 The pack is pushed up behind the soft
palate and the two ends of the tape
secured together firmly below the
anterior nares

67

68. Neurologic Examination(Disability)
 A brief neurological evaluation is performed to
establish
The patient’s level of consciousness
Pupillary size & reaction
 Lack of consciousness with altered pupil reaction to
light –immediate CT scan of the head-management
with mannitol or fluid restrictions
68

69. The committee on trauma of the American
college of surgeons recommends AVPU
system
 A rapid assessment of neurological disability is made
noting patients response on a 4 point scale
A - Responds appropriately, is aware
V - Responds to verbal stimuli
P - Responds to painful stimuli
U - Does not respond, unconscious
 In the absence of direct damage to the eye, pupil response
must be recorded.
69

70. EXPOSURE
Patient should be completely disrobed so that all the
body can be visualized, palpated, and examined for
injuries or bleeding sites.
70

71. Conclusion
 In the care of the patient with maxillofacial injuries, it is essential that
the surgeon have the knowledge and the ability to provide an
emergency airway.
 Surgeons must be technically prepared and psychologically willing to
perform procedures that may be life saving.
71

72. References
1. Miller’s Anaesthesia. Vol. I
2. Oral and Maxillofacial trauma. 2nd edition. eds
RJ Fonseca and RV Walker. 1997
3. Principles of Oral and Maxillofacial Surgery.
Peterson, Marciani, Roser and Indresano. Vol. I
Principles of Surgery. Part V - Principles and
Management of Maxillofacial Trauma. 1997
4. Rowe and Williams’ Maxillofacial injuries. Vol.
I. 2nd edition. J. Ll. Williams (ed.) 1994.
5. Oral and Maxillofacial Surgery. Vol. 3 –
Trauma. RJ Fonseca(ed). 1999.
72

74. Head Injuries
 C – consciousness
 R – respiration
 A - Trauma
 N – Neck
 Cervical/Carotid Injury
 E- Eyes
 Pupils
 Extra ocular muscles
 Corneal reflexes
 Occulovestibular and occulocephalic reflexes
 A - Airway
 Gag relex
 L- Limbs
 Motor examination
 Reflexes
 Sensation

75. HEAD INJURIES
These may include injuries of the scalp, skull, brain, and
blood vessels.
Scalp Injuries
1. Laceration of the scalp may be associated with significant
bleeding. Control with deep sutures and compression dressing. Prophylactic
antibiotics for Scalp infections as they may spread intracranially via
the emissary veins.
2. Skull fractures are described according to shape, displacement,
site and integrity of the overlying skin. Thus we have, for example,
linear, stellate, comminuted, depressed, compound, and basilar
fractures.
 A fracture can be diagnosed by digital exploration of the wound,
radiographically or clinically. The diagnosis of basilar fractures is often
clinical:
 CSF leaking from the nose or ear.
 Periorbital ecchymosis (raccoon eyes).
 Ecchymosis behind the ear (Battle's sign).

76. Physical Examination
 1. Assess level of consciousness. Use the Glasgow Coma Scale. The minimum
score is 3 and the maximum score is 15. An intubated patient has a maximum
GCS 11T. A score of 8 or less signifies severe brain damage and the
prognosis is guarded.
 2. Check pupils (size, reaction to light).
 3. Check ears and nose for bleeding or CSF leakage.
 4. Check for ecchymosis around the eyes or behind the ears (basilar
fracture).
 5. Check cranial nerves.
 6. Exclude neck injury (neck pain, stiffness, tenderness, or paralysis are
suspicious signs).
 7. Limbs (strength, tone, reflexes)
 8. Vital signs (blood pressure, pulse, respiration, temperature)
 9. Associated injuries

77. Brain Injuries
 1. Concussion: No gross pathology. Transient loss of
consciousness. CT scan is normal.
 2. Contusion: Bruising of the brain surface underneath a
fracture or at the under-surface of the frontal and
temporal lobes, due to shearing forces. Diagnosed on CT
scan.
 3. Laceration: Tearing of the brain substance. Diagnosed
by CT scan.
 4. Brain edema: This is localized in the glial cells, myelin
sheaths, and intercellular spaces. It causes increased
intracranial pressure, which may impair brain circulation,
or result in brain herniation. It may be missed in early CT
scans. Later CT scans or MRI show edema more reliably.

78. Brain damage is classified into:
1. Primary brain damage. It occurs at the time of injury
and is irreversible (i.e. lacerations, contusions, axonal
injuries of the white matter due to shearing forces).
2. Secondary brain damage. It occurs at a later stage
due to tissue hypoperfusion and may be preventable
and reversible. Conditions that may cause secondary
brain damage:
 Extracranial causes: shock, hypoxia, and electrolyte
abnormalities.
 Intracranial causes: hematoma, brain edema, infection,
and hydrocephalus
A minimum CPP of 70 mm Hg (or >50 mmHg in young
children)
(CPP = mean arterial pressure (MAP) – intracranial)

79. Intracranial Bleeding
 1. Epidural hematoma: Usually due to laceration of the middle
meningial artery or venous sinuses. Commonly located in the
temporal or parietal region, often with associated fractures. On
CT scan it appears as a hyperdense, biconvex-shape lesion.
 2. Subdural hematoma:
 a. Acute subdural: It manifests within the first few hours of injury. It is due to
bleeding from injured brain tissue or from the veins, which bridge the cortex
with the cavernous sinus. On CT scan it appears as a crescentshape, hyperdense
lesion.
 b. Chronic subdural: It may appear many days, weeks or months after the
injury. More common in elderly patients. On CT scan it shows as a crescent-
shape, hypodense lesion.

80.  3. Intracerebral hematoma: Usually beneath a cortical contusion.
 4. Subarachnoid hemorrhage: It often gives symptoms and signs of Meningial
irritation: headache, photophobia, neck stiffness, fever. The mental status may
vary from confusion to coma. On CT scan it appears as linear, highdensity
areas following the sulci, often in the Sylvian fissure. The blood is usually
absorbed by the CSF. It may cause late hydrocephalus because of obstruction
of the CSF circulation.
 A catastrophic complication in patients with intracranial hematomas is
herniation of the temporal lobe through the tentorium and compression of
the brain stem. Symptoms and signs:
 1. Dilatation of the ipsilateral pupil, due to compression of the third nerve. In the
early stages there may be transient constriction due to stimulation of the nerve.
 2. Depressed level of consciousness, due to compression of the reticular formation
 3. Contralateral hemiparesis, due to compression of the cerebral peduncle
 4. Bradycardia
 5. Elevated blood pressure
 6. Irregular respiration

81. Ocular function
 Reaction of pupils to light
 Extraocular muscle function
 Oculovestibular and oculocephalic reflexes
 Corneal reflex
 Gag reflex

82. Cranial nerve examination
 Olfactory nerve
 Optic nerve
 Occlumotar
 Trochlear
 Abducent
 Trigeminal nerve
 Facial nerve
 Vestibular nerve
 Glossopharyngeal nerve
 Spinal accesory nerve
 Hypoglossal nerve

83. Upper motor lesion Vs lower Motor lesion
 Mucle groups
 Rigid
 Slight wastine
 Flexor spams
 Brisks jerks
 Plantars extensor
 Normal electrical
reaction
 Individiual
 Flaccid
 Marked wasting
 Fasciculation
 Deep jerks absent
 Flexor plantars
 No or little reaction

84. Motor nerve examination
 Grade 0 – no motor activity
 Grade 1 – papable muscle contraction
 Grade 2 – complete range of motion with gravity eliminated
 Grade 3 – complete range of motion against gravity
 Grade 4 - complete range of motion against gravity with resistance
 Grade 5 – complete range of motion against gravity with complete resistance
Gait
•Casual , heal to toe and tandem walking to be examined
•Cerebellar dysfunction can cause ataxia of gait
•Unilateral cerebellar lesion will produce staggering toward the affected side
( typicall walk with the legs apart)
Coordination
•Ability to perform finger to nose, heel to shin, and rapid alternative movements
•Hemispheric cerebellar disease usually lateralize, middle vermian lesions affect
bilaterally

85. Sensory system
 Grade 0 – absent
 Grade 1 – present
 Grade 2 – normal
 Grade 3 – normal active
 Grade 4 – hyperactive
 Grade 5 – hyperactive with Clonus
Jaw jerk
Bicep jerk
Suppinator jerk
Tricep jerk
Knee jerk
Angle jerk
Babinskis sign

87. Diagnostic tests
 1. Plain skull x-rays only if CT scan is not available (may show fractures, foreign
bodies, air in the skull, shifting of calcified midline structures). A linear
fracture increases the risk of intracranial hematoma by 400 times.
 2. Cervical spine x-rays and CT scan for all unconscious patients and those
with suspicious symptoms (local tenderness, neurological signs).
 3. CT scan: This is the most important diagnostic tool.
 Indications: All patients with history of loss of consciousness, amnesia, depressed level of
consciousness, headache and localizing signs should have a CT scan investigation. Subsequent
CT scan may be necessary if there is deterioration of the neurological status.
 4. Carotid angiogram (limited use). It might be useful in some penetrating
injuries, especially with retained knife blades or bullet injuries.
 5. Intracranial Pressure (ICP) monitoring: It is an essential diagnostic,
monitoring, and therapeutic modality in severe head injuries. The CPP
(Cerebral Perfusion Pressure) is much more important than ICP absolute
values. Maintain a CPP >70 mmHg or >50 mmHg in young children.
SEND FOR NEUROLOGICAL CONSULTATION

88. Management of Scalp injuries
 Scalp lacertations:Copius irrigation to cleanse the wound,
carefull debridement. Closure in layers
 Scalp avulsions: copius irrigation, trimming of edges. Primary
closure if avulsion is small. Large area to be covered with
suitable flap or left with external dressing for secondary
healing.

89. Managemet of Mild Head injury
GCS 14 - 15
• History
• Name/Age/Sex
• Mechanism of Injur
• +/- loss of consciousnes
• Level of alertness
• Amnesia –
Retrograd/anterograde
• Head ache- mild/moderate/sever
• +/-seizure
• GPE
• Limited
neurological
examination
• Cervical spine
radiographs
• Blood alcohol
• CT scan
• Admit/observe
• No CT Scan/Abnormal CT scan
• Penetrating Head Injuries
• Deteroriting Condition
• Moderate/sever head ache
• Alcohol intoxification
• Skull fracture
• CSF leak
• Amnesia
• H/O unconsciousnes
• Discharge
• Schedule follow up
with in 1 week

90. Management of Moderate head Injury (Flow Chart)
GCS 9-13
Admission
CT Scan of Brain
If patient improves discharge if patient detoriates, manage
as per severe head injury

91. Management in Case of Sever head injury
GCS score 3-8
• ABC
• Previous history for allergies,
medications, past illness, last
meals and events leading to
head injury
Neurologic Reevaluation
•Eye opening
•Motor response
•Verbal response
•Pupillary light reaction
•Occulo cephalics reflex
•Occulo vestibular reflex
Therapeutic Agents
•Mannitol
•Moderate
hyperventilation
•Anticonvulsants if
requireed
• CT scans
• Air
Venticulogr
am
• Angiogram

92. Skull fractures
 Skull fracture predispose a conscious to about 400
times the possibility of cranial haematoma and about
20 times in a comatose patient
 Classified as:
 Closed/open
 Linear/stellate/communited
 Depressed / non depressed

93. Management
 Closed non depressed fractures:- observation and monitoring
and medical line of treatment for associated intracranial
parenchymal injury
 Open non depressed fractures:- close observation, surgical
intervation if intracranial bleed is suspected/anticipated
 Depressed skull fractures:- observation, if no untoward
neurological sign exists than the operation may be delayed
and elevation of the fractured segment is done

94. Basal skull fractures
 Associated tear of the dura and arachnoid at the base of the skull/
middle or anterior cranial fossa
 Battles sign is suggestive of basal skull fracture
 A CSF fistula occurs in 70 % patients with in 48 hours of trauma
 98% of fistulae occur with in 3 months
 Post traumatic fistulae heal spontaneously with in week, and 80% heal
with in 6 months.
 Spontaneous reoccurance may be there after initial cessation
 Otoroheas almost always resolves spontaneously and delayed
otorrhea is rare
 Chronic fistulae are indicated for surgical repair

95. C/F
 Headache
 Decreased hearing
 Salty taste in mouth
 Pneumocephalus present in 30% of the patients
Diagnosis
Bed side: ring test
tram line
Lab test: glucose >30mg/dl
protein < 2/l
presence of b2 transferrin

96. Management
 There may be presence of meningitis - Prophylactic
antimicrobials (3rd
generation cephalosporins)
 Head elevated to 30 degrees, cautioned againts blowing nose,
forcefull coughing
 If leak persists for more than 72 hours, lumbar puncture is
indicated to reduce ICP
 Fewer than 5% patients require repair. Immediate surgical
intervention is indicated only open communited fractures with
CSF leak
 Delayed surgical repair is indiacted in
 Persistent or increased CSF leakage over 1 or 2 weeks
 Presence of unresolving pneumocephalus for more than a week
 meningitis

97. Cervical Spine Injuries
 Only 2% incidence of cervical spine injuries in maxillofacial
trauma patients
 Identification of obvious fracture , widening of posterior spina
process interspace
 CT scan is choice of diagnostic radiographic tool
 Emergency management include:
 ABC
 C-Spine stabilization using rigid and semi rigid collars
 30mg/kg predisonolone bolus followed by 5.4g/kg/hr for 24 hours
 Definitive management include skeletal traction, with the use of halo
traction with stryker frame with abouts 25 pounds of traction force

98. Orbital injuries
 Opthalmic exatmination:
Visual accuity
Enoptholmoses/proptosis/diplopia
 Eye movement
Size , level and reaction of pupils
Intra occular examination of choroid, anterior chamber, cornea,iris
 Extra ocular examination
 Lid integrity
 Nasolacrimal duct injury
 Echymosis
 Ptosis

100. 100
Hutchinson’spupil
•Seen in case of cerebral compression
•Consists of 3 stages
Pupil of the side of injury
contract
due to irritation of
occulomotor nerve
Pupil on other side -normal
pupil of the injured side
becomes
dilated due to paralysis of
occulomotor
nerve
Pupil of other side contracts
Pupils of both sides dilated, no
reaction
to light

101. 101
Pupillary response inference
Bilaterally reactive pupils that react to
both direct & consensual stimuli
Normal pupil
Bilateral small pupils Narcotics, pontine injury, early central
herniation on the pons
Bilateral fixed & dilated pupils Inadequate cerebral perfusion,severe
elevation of ICP preventing adequate blood
flow to brain
Unilateral fixed & dilated pupils. pupil that
does not constrict when light is directed at the
pupil but constricts when light is directed to
contralateral pupil
Traumatic optic nerve injury
(Marcus Gun pupil)
A core optic pupil (pupil that appears irregular
in shape)
Lack of coordination of contraction of the
muscle fibers of the iris and is associated with
midbrain injuries
Unilateral dilated pupil that does not respond
to either direct or consensual stimulation
Transtentorial Herniation

102. 102
Cranial nerve 3,4,6:
- light reflex
- intorsion and extorsion

103. Vision-threatening injuries (VTI)
 These include:
 Retrobulbar haemorrhage;
 Traumatic optic neuropathy;
 Open and Closed globe injuries;
 Loss of eyelid integrity;
 Chemical injury.
 Loss of sight following blunt facial trauma may be crudely considered to be
due to the following mechanisms.
 Direct injury to the globe;
 Direct injury to the optic nerve, e.g. bony impingement;
 Indirect injury to the optic nerve, e.g. deceleration injury resulting in shearing,
stretching forces;
 As a result of a generalised or regional fall in tissue perfusion (anterior
ischaemic optic neuropathy,
 retrobulbar haemorrhage, nutrient vessel disruption);
 Loss of eyelid integrity

104. Retrobulbar haemorrhage
 A tense, proptosed globe and a dilated pupil may be the only
clues to the presence of a retrobulbar haemorrhage
 A lateral canthotomy, with lateral canthal tendon division, can
be performed under local anaesthesia in the emergency
setting. Lignocaine 1%, with adrenaline (1 in 200,000), is
injected into the lateral canthal area of the affected eye, the
lateral canthus incised to the orbital rim and the canthal
tendon identified and cut. The lower eyelid is then pulled
forward and its lateral attachment to the orbital rim divided.
 This allows the globe to translate forward, partially relieving
the pressure by increasing the retrobulbar volume. If
necessary, the same procedure can also be applied to the
upper eyelid laterally. Formal decompression is then carried
out under a general anaesthesia

106. CHEST INJURIES
Rib trauma is occurs in aout 56% of poly trauma patients followed by pneumothorax,
flail chest, injuty to heart and major vessles
Degree of injury to chest is not indicative of the severity of injury to inner structures
During the Primary Survey, the following life-threatening conditions from the chest
should be identified and treated:
 1) Tension pneumothorax
 2) Fail chest
 3) Open, blowing chest wound
 4) Massive hemothorax
 5) Cardiac tamponade
During the Secondary Survey, the following injuries should be identified and treated:
 1) Contained rupture of the aorta
 2) Perforation of the tracheobronchial tree
 3) Perforation of the esophagus
 4) Rupture of the diaphragm/trachea
 5) Myocardial contusion
 6) Pulmonary contusion

107. PNEUMOTHORAX
Definition: The presence of free air in the pleural cavity.
Symptoms and signs
1. Often asymptomatic.
2. Dyspnea, tachypnea.
3. Diminished breath sounds, hyperresonance, poorly
moving hemithorax.
Investigations
Chest x-ray, preferably erect and in expiration

108.  HEMOTHORAX
Definition: Free blood in the pleural cavity.
Symptoms and signs
1. Often asymptomatic.
2. Dyspnea, tachypnea, hypovolemia.
3. Diminished breath sounds, dullness on
percussion, poorly moving hemithorax

109. TENSION PNEUMOTHORAX
Definition: Air under pressure in the pleural cavity due
to a valve effect. Associated with life-threatening
cardiorespiratory compromise due to collapse of the
affected lung, compression of the normal lung and
decreased venous return.
Symptoms and signs
Dramatic presentation. Panicky patient.
Dyspnea, cyanosis, tachypnea,
Shock, distended neck veins.
Deviated Trachea to opposite side
Absent breath sounds, hyperresonance on affected side.
Prominent hemithorax with no movement on respiration

110. Flail Chest
 Occur as a result of three or more contigous ribs fracturedd at two
points
 Lateral type of flail chest is more common
 Anteior type occures when ribs become separated at the
costrochondral junction, with or without associated fracture of
sternum.
 The posterior type occurs whe n the posterior ribs are fractured
 Pulmonary contusion, hemothorax and pneumothorax may be
associated with flail chest,
 Mechanical ventilation is indicated
 Tachyapnea
 Shallow rapid breaths
 Distended neck veins
 hypercapnea

111. Placement of thoracic tube

112. Abdominal Injuries
The abdomen is systemically examined by inspection,
palpation and auscullation and percussion
Injury to be suspected in deacceleration injuries, blunt
trauma apart from penatrative injuries
Presence of haematuria in Routine urine examinatio
may indicate a renal/genito urinary trauma
Serum amylase a non specific test in presence of
abdominal pain is significant
LFT should also be advised to check liver injuries
Dignostics include USG, CT Scan PA abdomen and DPL

113. DPL (diagnostic peritonial Lavage)
 Indicated in patients with + H/O abdominal trauma with
abdominal pain /tenderness.
 Objective is to obtain fluid from the pelvic fossa for analysis
 Bladder should be emptied to avoid injury during DPL.
 Aspiration of fluid is done, if no fluid is obtained tha n 20ml/kg of
RL is infused upto 1 Litre and removed fluid should atleast be in
range of 500-700 ml.
 Three methods:
 Closed type: catheter blindly inserter below the umblicus in to the
peritoneal cavity. Highest incidence of complication, false negative tests
and iatrogenic injury to visecral organs
 Semiopen type: 2-3 cm infraumblical skin incision, blunt dissection.
Incision into fascia. Insertion of trocar
 Open technique: insertion of the catheter direct vision. Safest and
guarantees intraperitoneal placement

115. Managemet of abdominal injuries
 Physical examination to be repeated every 6 hourly
 Management of shock, sepsis
 Surgical exploration and intervention when
necessary
 Monitoring of urine output every hourly
 Patient to be NPO
 Nutritional support

116. Urological injuries
 Occurs in 10% polytrauma patients
 Majority of injuries are non threatning
 Evaluation of kidneys, ureter, bladder, urethra and genitila
 Excellent healing capibilities of genitourinary tract, if urinary
flow can be maintained without obstruction than healing is
likely with just medical intervention
 Kidney is the most common urologic organ to be injured
 CT scan is the gold standard for diagnosing renal injuries

119. Skeletal injuries

120. Retrograde intubation

121. Submental intubation