Assists with airway management and ventilation. 3. Doctor 1 (Emergency Physician or Surgeon)  Assesses and manages circulation. 4. Doctor 2  Assists with primary survey and resuscitation. 5. Nurse 1 (ED Nurse, ‘Airway’)  Assists with airway management and ventilation. 6. Nurse 2 (ED Nurse, ‘Circulation)  Assists with circulation assessment and management. 7. Scribe (ED Nurse, Paramedic, Health Care Assistant)  Records details of assessment, treatment and monitoring. 8. Radi

1. MANAGEMENT OF MAJOR
TRAUMA
DR RIZWAN ANSARI
FCPS ANESTHESIOLOGY

2. You are called to accident and emergency to
see a 53-year-old female after a road traffic
accident. The patient had been involved in a
collision with a car and had a prolonged
extraction at the scene due to entrapment.
On examination
She is confused lethargic , Bp 90/77 , pulse
150bpm, Respiratory Rate 25brpm , decreased
pulse pressure , urine out put was negligible.

3. INTRODUCTION
 Every five seconds someone in the world dies as a result of an
injury
 Injuries kill about 5.8 million people each year ; more than
malaria, tuberculosis and HIV/AIDS combined
 Among the causes of injury are acts of violence, road traffic
collisions, burns, drowning, falls and poisoning. Road traffic
injuries are the leading cause of injury-related deaths
worldwide.

4. Trauma scoring system

5.  Most widely used field triage tool
 lower score indicates higher severity
 RTS <4 proposed for transfer to trauma center
REVISED TRAUMA SCORE

6. HOW WILL YOU MANAGE MAJOR TRAUMA?

8. PRIMARY SURVEY AND RESUSCITATION
 The purpose of the primary survey is to identify immediate life
threatening conditions.
 What is beck’s triad and flial chest?

9.  A flail chest occurs when two or more ribs are fractured in two or
more places
 Beck’s triad consists of :
 venous pressure elevation,
 Decline in arterial pressure
 muffled heart

10. CATASTROPHIC HEMORHAGE CONTROL
 The use of tourniquets is now recommended for
the management of life threatening Obvious
bleeding from open extremity injuries

11. AIRWAY AND CERVICAL SPINE CONTROL
 The airway may be soiled with vomit, blood or foreign
material. Blunt or penetrating injuries that obstruct the airway
include maxillary, mandibular and laryngotracheal fractures
and large anterior neck haematomas.
 Immobilization of the cervical spine must be continued,
until a complete clinical and radiological evaluation has
ruled out injury.
 Should be consider full stomach

12. How will you stabelize cervical spine?

13.  This can either be done manually (manual in-line
stabilisation of the neck - MILS) or with a correctly sized
hard cervical collar, lateral blocks (or sandbags), and straps
across the forehead and chin piece of the collar
 A jaw thrust may be better at relieving airway
obstruction with decreased consciousness than a chin
lift.

14. HOW WILL YOU INTIBUTATE MAJOR TRAUMA PATIEN

16. Failed intubation
 Failed or difficult intubation is a common problem in this
setting
 DO not waste time with repeated attempts at intubation,
while patient is desaturating.
 If intubation is impossible, a laryngeal mask airway (LMA)
will provide a temporary airway, but may not prevent
aspiration. ILMA can be used for intubation.
 If this fails, a cricothyroidotomy should be carried out

17. BREATHING
 Ventilation requires adequate function of the lungs, chest wall
and diaphragm
 Each component must be examined and evaluated rapidly. The
patient’s chest should be exposed and any obvious injuries
noted.

18. CIRCULATION
• The second step is to identify the probable
cause of the shock state
• Haemorrhage is the most common cause of
shock after injury and accounts for up to 50% of
deaths in the first 24 hours after injury.
 Management of shock
• The first step is to recognise its presence

19. Signs of haemorrhagic shock
 Blood pressure
 Pulse rate
Respiratory rate
 Pulse pressure
 Urine output
 Mental status

20. Classification of haemorrhagic shock

21. Haemorrhage can be classified into 4 classes
Why pulse pressure decrease in hemorrhage?

22.  Attention must be paid to an increased respiratory
rate and narrowed pulse pressure (the difference
between systolic and diastolic pressure).
 Relying on systolic blood pressure as the only
indicator of shock leads to delayed recognition of
shock.
 compensatory mechanisms prevent the systolic blood
pressure from falling until up to 30 percent of the patient’s
blood volume is lost

23. Management of haemorrhagic shock
 BLEEDING CONTROL and prevention of the LETHAL TRIAD OF
DEATH are key to the management of haemorrhagic shock.

24. TRAUMA TRIAD OF DEATH

25. Lethal triad
 Causes of Coagulopathy
HAEMORRHAGE result in the consumption of coagulation
factors and early coagulopathy.
MASSIVE TRANSFUSION, with the resultant dilution of platelets
and clotting factor
 Effect of HYPOTHERMIA on platelet aggregation and the clotting
cascade.

26.  Measurement of international normalized ratio (INR),
activated partial thromboplastin time (APTT), fibrinogen
and platelets to rule out coagulopathy
 Consideration of early blood component therapy, including
fresh frozen plasma (FFP), platelets and cryoprecipitate,
should be given to patients with class 4 haemorrhage.
 A fibrinogen of less than 1g or a prothrombin time (PT)
and APTT of >1.5 times normal, represents established
haemostatic failure and is predictive of microvascular
bleeding

27.  1. DAMAGE CONTROL RESUSCITATION
 WE CAN PREVENT LETHAL TRIAD OF DEATH BY TWO STRATEGIES
 2.DAMAGE CONTROL SURGERY

28. DAMAGE CONTROL RESUSCITATION
 1. Permissive hypotention MAP 50-60
 2. Minimizing crystalloid
 3. 1:1:1 blood product ratio
 4. Early haemorrhage control

29. Damage control surgery
 It is the surgical intervention to stop hemorrhage and
limit GIT contamination of abdominal compartment.
 Surgery is limited to the control of uncompressible
haemorrhage and the insertion of vascular shunts

30.  Insert two large bore (minimum 16 gauge) peripheral
intravenous (IV) cannulas
 At the time of IV insertion, take blood for type and crossmatch and
baseline haematologic studies, PT ,APTT, INR, Fibronogen levels ,
ABGs , pregnancy test for all females of childbearing age.
 central venous lines should be used
 Insert an arterial cannula for blood gas sampling and invasive
blood pressure monitoring
 Fluid warmer , Rapid infuser devices , forced air warmer
PREPARATION FOR
RESUSCITATION

31. What fluid would you give to resuscitate the patient?

32.  Crystalloid; Hartmann’s in 3:1 ratio to blood loss –
adequate for Class 1 and 2 haemorrhage and initial
resuscitation of higher classes
 Colloid; 1:1 ratio with blood loss – no proven
benefit over crystalloid
 The goal of resuscitation is to restore organ perfusion

33. Blood Replacement
 The main purpose of blood transfusion is to restore
the oxygen carrying capacity
 A target haemoglobin (Hb) of 7-9 g.dl is recommended
 If group-confirmed blood is unavailable, type O packed
cells are indicated
 1:1:1 Red cell:FFP:Platelet regimens are reserved for the
most severely traumatised patient(massive transfusion
protocol)

34. Disability - Rapid neurological assessment
 A simple pneumonic for a crude but simple GCS assessment
is AVPU
 Patients who score ‘P’ or ‘U’ on the AVPU scale are likely to
need intubating. ‘P’ roughly corresponds with a GCS of 8/15.

35. Exposure
 Undress the patient completely and protect from hypothermia with
warm blankets or a hot air blower.

36. SECONDARY SURVEY
 when the patient has been initially stabilised; it is a top
to toe examination
 ‘AMPLE’ history should be obtaind as a minimum.

37. TRANSFER TO DEFINITIVE CARE
 Timing of transfer is largely based on the stability of the
patient; damage control surgery may be required prior to
transport
 Once the decision is made to transfer, good
communication between referring and receiving
facilities is crucial

38. THANK
YOU

40. Thromboelastography (TEG) and rotational elastometry (ROTEM) allow more
specific use of blood components by addressing the specific deficiencies rather
than relying solely on the 1:1:1 transfusion ratio DCR approach.
Both TEG and ROTEM demonstrate the rate of clot formation and clot stability,
reflecting the interactions between the coagulation cascades, platelets, and the
fibrinolytic system

41. TRAUMA TEAM

42. Objectives of the trauma team
 Identify and correct life threatening injuries.
 Resuscitate the patient and stabilize vital signs.
 Determine the extent of other injuries. Prepare the patient for
definitive care, which may mean transport to another centre.

43. COMPOSITION OF TRAUMA TEAM
Total 10 members are involved in trauma team. Can be reduced in limited
resources.
1. Team Leader (Emergency Physician)
2. Anaesthetist
3. Airway Assistant (ANESTHESIA TECH)
4. Doctor 1 (Emergency Physician or Surgeon)
5. Doctor 2
6. Nurse 1 (ED Nurse, ‘Airway’)
7. Nurse 2 (ED Nurse, ‘Circulation)
8. Scribe (ED Nurse, Paramedic, Health Care Assistant)
9. Radiographer
10.Specialists

44.  The overall management of the patient is the responsibility of
the team leader
 The trauma team’s responsibility is to complete the Primary
survey and necessary resuscitation and subsequently
complete the Secondary survey
 It is strongly recommended that any member of staff who
could be involved in the resuscitation of a trauma patient
should complete an ATLS

45. Trauma team roles and responsibilities
1. Team Leader (Emergency Physician)
 Controls and manages the resuscitation. Makes
decisions; prioritises investigations and treatment.

46. 2. Anaesthetist
 Responsible for assessment and management of the airway
and ventilation.
 Maintains cervical spine immobilisation .