2. RTA
• Road traffic injuries cause more than 1 million
deaths annually and about 20 to 50 million
significant injuries worldwide.
• More than 90% of car accidents occur in
developing countries.
• In Egypt, road traffic deaths in 2010 were
estimated to be 10,729 according to the annual
report of World Health Organization (WHO).
• The total number of accidents in Cairo-Egypt and
on its travel roads in 2013 is 13,957 with a 24%
increase from 2012.
3.
4. The wreckage of a minibus lies at the site of an accident near a railway crossing in Dahshur,
Egypt, November 18, 2013.
7. Initial assessment
1. Primary survey (ABCDE).
2. Resuscitation.
3. Adjuncts to primary survey and resuscitation.
4. Secondary survey (head- to- toe evaluation + AMPLE history.
5. Adjuncts to secondary survey.
6. Continuous monitoring and re-evaluation.
7. Definitive care.
8. Primary Survey
• The patient is assessed for life-threatening
injuries + starting management simultaneously.
• Adhere to the following sequence of priorities:
1. Airway maintenance and protection of cervical
spine.
2. Breathing and ventilation.
3. Circulation with haemorrhage control.
4. Disability; Neurological status.
5. Exposure with prevention of hypothermia.
18. Mechanism of Injury
It determines what
organs are probably
injured.
Why is it important to know?
19. Compression
Crushing
Shearing
Deceleration (fixed organs)
Blunt Force Mechanism
How does it injure?
Liver and spleen
20. Blunt Force Mechanism
Spleen (40 – 55%)
Liver (35 – 45%)
Small bowel (5 – 10%)
There is 15% incidence of retroperitoneal haematoma
during laparotomy for blunt abdominal trauma
What organs are commonly injured?
21. Seat Belt abdominal injuries
• Rupture of upper abdominal viscera (shoulder
harness)
• Tear or avulsion of mesentry.
• Small bowel or colon.
• Chance fracture of lumbar vertebrae.(hyper
flexion).
• Pancreatic.
• Duodenal.
22. Stab
Low energy
Lacerations
Gunshot
Transfer of kinetic
energy
Cavitation (lateral damage)
falling
Fragments
Penetrating Mechanism
How does it injure?
High energy
23. Penetrating Mechanism
Liver 40%
Small bowel 30%
Diaphragm 20%
Colon 15%
spleen
Low Energy High Energy
Small bowel 50%.
Colon 40%.
Liver 30%.
Vascular structures 25%.
Common injuries?
Explosive devices:
1. Penetrating fragments
2. Blunt injuries
3. Blast pressure injuries
24. Assessment: History
Blunt
Speed
Point of impact
Intrusion
Safety devices
Position
Ejection
Penetrating
Weapon
Distance
Number of wounds
Amount of external bleeding.
28. Evidence of abdominal injury by
mechanism, history, or evaluation
Hypotension
Positive FAST or grossly positive DPL
Absence of massive hemothorax on
chest x-ray
Abdominal injury causes shock?
29. Adjunct: Gastric Tube
Relieves distention
Decompresses stomach before DPL.
To avoid aspiration.
Caution
Fracture skull base / facial fractures
May induce vomiting / aspiration
Blood in gastric secretions.
30. Adjunct: Urinary Catheter
Monitors urinary output
Decompresses bladder before DPL
Diagnostic
Caution
Do not insert the catheter if there is one of the following:
1. Inability to void.
2. Unstable pelvic fracture.
3. Blood at the urethral meatus.
4. Scrotal and perineal haematoma.
5. High riding prostate.
Retrograde urethrography should be done first.
31. Adjuncts: X-ray Studies
Routine
Blunt: AP chest, pelvis and cervical spine
Penetrating: AP chest and abdomen with markers (if
hemodynamically normal) to all entrance and exit
wound sites.
33. Special Studies in Blunt Trauma
Time
Transport
Sensitivity
Specificity
Eligibility
DPL FAST* CT
Rapid Rapid Delayed
No No Required
High High? High
Low Intermediate High
All
patients
All patients Hemodyna-
mically normal
* Operator dependent
34. Diagnostic Studies: Penetrating
Lower chest wounds: Serial exams, thoracoscopy,
laparoscopy, or CT scan
Anterior abdominal stab wounds: Wound exploration,
DPL, or serial exams
Back and flank stab wounds: DPL, serial exams, or
double- or triple-contrast CT scan
35. Indications for celiotomy?
Blunt Trauma
BP, suspect visceral injury
Free air
Diaphragmatic rupture
Peritonitis
ve DPL, FAST, or contrast CT
40. Pelvic Fractures
Assessment
Inspection
Palpate prostate
Leg-length discrepancy, external rotation
Pain on palpation of bony pelvic ring
Pelvic ring instability:
41. Pelvic Fractures
Emergency Management
Fluid resuscitation (Hypovolaemic shock)
Determine if open or closed fracture
Splint pelvic fracture
Determine associated perineal / GU injuries
Determine need for transfer
42. Shock
• It is a systemic state of inadequate tissue
perfusion and oxygenation.
• It is the most common cause of death among
surgical patients.
• Hypovolaemic shock is the most common form
of shock and is a component of other forms of
shock.
43. Shock in trauma patient
Haemorrhagic .
Non-haemorrhagic:
• Tension pneumothorx.
• Cardiogenic .
• Neurogenic.
• septic
In injured patient, haemorrhage is the most common cause of shock.
48. Responses to fluid resuscitation
2000 ml of warm isotonic solution in adult and 20 ml/Kg of Ringer’s lactate in children given as fast as
possible.
50. Blood transfusion
1492 Pope Innocent VIII is said to have been
given the world’s first blood transfusion by
his Jewish physician who made him to
drink blood of three 10-year-old boys.
1829 James Blundell makes the first successful
human transfusion in women with post-
partum haemorrhage.
1926 The British Red Cross institutes the first
blood transfusion service in the world.
1939 The Rhesus system is identified and
recognized as major cause of transfusion
reaction.
James Blundell
51. Blood and blood products
• Whole blood: rarely available.
• Packed red cells:
– 330 ml and has haematocrit of 50-70%.
– It is stored in SAGM (saline-adenine- glucose-mannitol).
– Shelf time 5 weeks at 2-6°C.
• Fresh frozen plasma (FFP):
• Rich in coagulation factors.
• Stored at -40 to -50°C.
• Shelf-time 2 years.
• coagulopathy.
• Platelets:
– Stored at 20 – 24 °C (room temperature).
– Shelf time 5 days.
– They are given in thrombocytopeic patients who are bleeding or undergoing surgery.
• Cryoprecipitate:
• It the supernatent precipitate of FFP.
• It is rich in factor VIII and fibrinogen.
• Stored at -30°C with 2- yearsshelf –life.
• Prothrombin complex concentrates (PCCs):
• It contains factors II, VII, IX and X.
• Half life of factor II 60 – 72 h while others 6 – 24 h.
• It is the reversal of oral anticoagulant (warfarin).
52. Indications for blood transfusion
• Acute blood loss.
• Peri-operative anaemia:
• Symptomatic chronic anaemia.
Hg level (g dl¯¹ )
< 6 Indicated for transfusion.
6 - 8 Transfusion if there Is bleeding, impending surgery.
> 8 No indication for transfusion.
54. Massive blood transfusion
• It is the replacement of blood volume in 24 hours or >
50 % within 4 hours.
• Coagulopathy.
• Hypocalcaemia.
• Hyperkalaemia.
• Metabolic alkalosis.
• Hypothermia:
– Coagulopathy.
– Hypocalcaeia.
– Decrease O2 delivry to tissue (O2 diss. Curve to right).
• Acute lung injury
55. Management of coagulopathy
• FFP if PT and PTT > 1.5 of normal.
• Cryoprecipitate if fibrinogen < 0.8 g/L.
• Platelets if platelet count < 50 00 /cu mm.
59. Key concepts
1. Bombs and explosions can cause unique pattern of
injuries rarely seen in civilian trauma.
2. Post explosion injuries involve both blunt and penetrating
trauma.
3. Expect half of all initial casualties to present in ER in one-
hour period.
4. Most severely injured arrive after the less injured (upside-
down triage).
5. Explosions in confined spaces are associated with great
morbidity and mortality than that in open air.
6. Blast lung is the most common fatal injury among initial
survivors.
7. Repeatedly examine and assess the patients.
68. Primary Unique to HE.
Results from the impact of the
pressure wave with body
surfaces.
(Blast wave)
Gas filled structures are
most susceptible
- middle ear
-lungs.
-GI tract.
- TM rupture and middle ear
damage
- Blast lung (pulmonary baro-
traumas)
- Abdominal hemorrhage
and perforation
- Globe (eye) rupture
- Concussion without physical
signs of head injury.
Secondary Results from flying debris and
bomb fragments
Any body part may be
affected
- Penetrating or blunt injuries
-Eye penetration (can be
occult)
Tertiary Results from individuals being
thrown by the blast wind
Any body part may be
affected
- Fracture and traumatic
amputation
- Closed and open brain injury
Quaternary - All explosion-related injuries,
not due to primary, secondary or
tertiary mechanisms.
- Includes exacerbation or
complications of existing
conditions.
Any body part may be
affected
- Burns.
- Crush injuries
- Closed and open brain injury
- Respiratory problems from
inhaling dust, smoke, or toxic
fumes.
- Angina
- Hyperglycemia
-Hypertension
Category Mechanism Body Part Affected Types of Injuries
Classification
69. Casualties
• Multiple casualties
• Mass casualties
• Triage :
– it is a process of determing the priority of patient
treatment.
– Priority was given to patients who has greatest chance of
survival.
– Tags or markers
– At different levels:
• At the scene of trauma
• on arrival
• Re-triage
70. Triage Scenario
• You are the only doctor available in ER with
one nurse to assist you. 2 ambulance arrived
with 5 patients who were passengers
travelling in bus before it crashed in a collision
• The injured patients are:
71. • 6-year-old boy is crying from severe pain in his
left thigh and asking for his mother.
• 45-year-old man. He is in severe respiratory
distress. Multiple contusion over the chest wall
he has Bp 120/80, pulse 120, RR40 and GCS 8.
• 38-year- old female thrown outside the bus and
has unstable pelvis. The Bp 80/40, pulse 140, RR
25 and she is alert.
• 50-year-old man breathless and not moving. He
has burst abdomen with intestines coming out
and he lost considerable amount of his blood.
• Pregnant women in 3rd trimester who is shouting
and has abdominal pain with normal vital signs.
72. Questions
• Give short account on causes, diagnosis and treatment
of airway obstruction in trauma patient.
• Discusses the management of shocked in trauma
patient.
• Classification and management of hemorrhagic shock
in trauma patient.
• Discuss the management of life-threatening injuries in
trauma patient.
• Give short account in penetrating abdominal injury.
• Mangement of traumatic fracture pelvis.
• Give short account on blast injury.
