Trauma Lecture

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Trauma Lecture

  1. 1. Principles of Trauma Management www.hi-dentfinishingschool.blogspot.com
  2. 2. Trauma <ul><li>Prehospital phase and triage </li></ul><ul><li>Primary Survey </li></ul><ul><li>ABCDE </li></ul><ul><li>Resuscitation </li></ul><ul><li>Adjuncts to primary survey and resuscitation </li></ul><ul><li>Secondary Survey </li></ul><ul><li>Records, Consent, Forensic evidence </li></ul>
  3. 3. Primary Survey <ul><li>A irway and cervical spine control </li></ul><ul><li>B reathing </li></ul><ul><li>C irculation with control of hemorrhage </li></ul><ul><li>D isability </li></ul><ul><li>E xposure/environment (expose patient, but avoid hypothermia) </li></ul>
  4. 4. Resuscitation <ul><li>Oxygenation and Ventilation </li></ul><ul><li>Shock management </li></ul><ul><li>IV lines—Normal Saline </li></ul><ul><li>Management of life-threatening problems </li></ul>
  5. 5. Adjuncts to Primary Survey and Resuscitation <ul><li>Monitoring: </li></ul><ul><ul><li>ABGs and ventilatory rate </li></ul></ul><ul><ul><li>End-tidal CO2 </li></ul></ul><ul><ul><li>EKG </li></ul></ul><ul><ul><li>Pulse oximetry </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul>
  6. 6. Adjuncts to Primary Survey and Resuscitation <ul><li>Urinary and gastric catheters </li></ul><ul><li>X-rays and diagnostic studies </li></ul><ul><ul><li>Chest </li></ul></ul><ul><ul><li>Pelvis </li></ul></ul><ul><ul><li>C-spine </li></ul></ul><ul><ul><li>FAST / CT SCAN / DPL </li></ul></ul>
  7. 7. Trauma Mortality <ul><li>35 per 100,000 population </li></ul><ul><li>Most common cause of death in children </li></ul>
  8. 8. Airway and Ventilation <ul><li>These are first priorities!!!! </li></ul><ul><li>Risks for obstruction: </li></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><ul><li>Maxillofacial trauma </li></ul></ul><ul><ul><li>Neck trauma </li></ul></ul>
  9. 9. Airway and ventilation <ul><li>Neck trauma: disruption of the larynx or trachea-or compression by soft tissue injury </li></ul><ul><li>Laryngeal trauma: </li></ul><ul><ul><li>Hoarseness </li></ul></ul><ul><ul><li>Subcutaneous emphysema </li></ul></ul><ul><ul><li>Palpable fracture </li></ul></ul>
  10. 10. Airway and ventilation <ul><li>Obstruction: </li></ul><ul><ul><li>Agitation or obtundation </li></ul></ul><ul><ul><li>Abnormal airway sounds </li></ul></ul><ul><ul><li>Trachea not in midline </li></ul></ul>
  11. 11. Airway and ventilation <ul><li>Inadequate ventilation </li></ul><ul><ul><li>Asymmetric chest rise </li></ul></ul><ul><ul><li>Asymmetric chest sounds </li></ul></ul><ul><ul><li>Poor oxygenation </li></ul></ul>
  12. 12. Airway and ventilation <ul><li>Airway Maintenance </li></ul><ul><ul><li>Chin lift </li></ul></ul><ul><ul><li>Jaw thrust </li></ul></ul><ul><ul><li>Oropharyngeal airway </li></ul></ul><ul><ul><li>Nasopharyngeal airway </li></ul></ul><ul><li>Definitive Airway </li></ul><ul><ul><li>Endotracheal tube </li></ul></ul><ul><ul><li>Cricothyroidotomy </li></ul></ul>
  13. 13. Airway and ventilation <ul><li>PaO 2 Levels </li></ul><ul><ul><li>90 mm Hg </li></ul></ul><ul><ul><li>60 mm Hg </li></ul></ul><ul><ul><li>30 mmHg </li></ul></ul><ul><ul><li>27 mmHg </li></ul></ul><ul><li>O 2 Hgb Saturation </li></ul><ul><ul><li>100% </li></ul></ul><ul><ul><li>90% </li></ul></ul><ul><ul><li>60% </li></ul></ul><ul><ul><li>50% </li></ul></ul>
  14. 14. Pulse Oximetry <ul><li>LED absorbed differently between oxygenated and non-oxygenated Hgb </li></ul><ul><li>Affected by: </li></ul><ul><ul><li>Poor perfusion </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Carboxyhemoglobin or methehemoglobin </li></ul></ul><ul><ul><li>Circulating dye </li></ul></ul><ul><ul><li>Patient movement, ambient light or signals </li></ul></ul>
  15. 15. Thorax <ul><li>Breathing: </li></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Open pneumothorax (“sucking wound”) </li></ul></ul><ul><ul><li>Flail chest </li></ul></ul><ul><ul><li>Massive hemothorax </li></ul></ul>
  16. 16. Thorax <ul><li>Tension Pneumothorax </li></ul><ul><ul><li>Collapse of affected lung </li></ul></ul><ul><ul><li>Decreased venous return </li></ul></ul><ul><ul><li>Decreased ventilation of opposite lung </li></ul></ul>
  17. 17. Thorax <ul><li>Tension pneumothorax: </li></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Distended neck veins </li></ul></ul><ul><ul><li>Unilateral decrease in breath sounds </li></ul></ul><ul><ul><li>Hyperresonance </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><li>Needs immediate decompression! </li></ul>
  18. 18. Thorax <ul><li>Open pneumothorax: </li></ul><ul><ul><li>Occlusive dressing </li></ul></ul><ul><li>Flail chest: </li></ul><ul><ul><li>Trauma principles and ventilation </li></ul></ul><ul><li>Massive hemothorax </li></ul><ul><ul><li>Chest decompression </li></ul></ul>
  19. 19. Thorax <ul><li>Circulation: </li></ul><ul><ul><li>Massive hemothorax </li></ul></ul><ul><ul><ul><li>Flat v. distended neck veins </li></ul></ul></ul><ul><ul><ul><li>Shock with no breath sounds </li></ul></ul></ul><ul><ul><ul><li>Treat with decompression </li></ul></ul></ul>
  20. 20. Thorax <ul><li>Circulation: </li></ul><ul><ul><li>Cardiac tamponade </li></ul></ul><ul><ul><ul><li>Decreased arterial pressure </li></ul></ul></ul><ul><ul><ul><li>Distended neck veins </li></ul></ul></ul><ul><ul><ul><li>Muffled heart sounds </li></ul></ul></ul><ul><ul><ul><li>PEA (pulseless electrical activity) </li></ul></ul></ul><ul><ul><ul><li>Treat with decompression </li></ul></ul></ul>
  21. 21. Thorax <ul><li>Resuscitative thoracotomy: </li></ul><ul><ul><li>Penetrating trauma </li></ul></ul><ul><ul><li>Pulseless with myocardial activity </li></ul></ul><ul><ul><li>Evacuate blood </li></ul></ul><ul><ul><li>Stop bleeding </li></ul></ul><ul><ul><li>Cardiac massage </li></ul></ul><ul><ul><li>Cross clamp of aorta </li></ul></ul><ul><ul><li>Infusion of fluids and blood </li></ul></ul>
  22. 22. Thorax Secondary Survey <ul><li>Simple pneumothorax </li></ul><ul><li>Hemothorax </li></ul><ul><li>Pulmonary contusion </li></ul><ul><li>Tracheobronchial tree injury </li></ul><ul><li>Blunt cardiac injury </li></ul><ul><li>Aortic disruption </li></ul><ul><li>Diaphragm injuries </li></ul><ul><li>Mediastinal traversing wounds </li></ul><ul><li>Esophageal rupture </li></ul><ul><li>Rib, sternum, scapular fractures </li></ul>
  23. 23. Shock <ul><li>Hemorrhage is the most common cause of shock in the injured patient!! </li></ul>
  24. 24. Shock <ul><li>Hemorrhagic shock </li></ul><ul><li>Non-hemorrhagic shock: </li></ul><ul><ul><li>Cardiogenic </li></ul></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Neurogenic shock </li></ul></ul><ul><ul><li>Septic shock </li></ul></ul>
  25. 25. Shock <ul><li>Blood volume: </li></ul><ul><ul><li>5 liters in the 70 kg adult </li></ul></ul><ul><ul><li>80-90 ml/kg in the child </li></ul></ul><ul><li>Classes of Hemorrhage (% loss) </li></ul><ul><ul><li>I: <15% </li></ul></ul><ul><ul><li>II: 15-30% </li></ul></ul><ul><ul><li>III: 30-40% </li></ul></ul><ul><ul><li>IV: >40% </li></ul></ul>
  26. 26. Shock <ul><li>Initial Therapy: </li></ul><ul><ul><li>Stop the bleeding! </li></ul></ul><ul><ul><li>Vascular Access lines </li></ul></ul><ul><ul><ul><li>2 large bore IV lines </li></ul></ul></ul><ul><ul><ul><li>Intraosseous lines </li></ul></ul></ul><ul><ul><ul><li>Central lines </li></ul></ul></ul><ul><ul><li>Fluid bolus </li></ul></ul><ul><ul><ul><li>2 Liters NS: adult </li></ul></ul></ul><ul><ul><ul><li>20ml/kg: Child </li></ul></ul></ul>
  27. 27. Shock <ul><li>Assess: </li></ul><ul><ul><li>Capillary refill (should be < 2 sec) </li></ul></ul><ul><ul><li>Peripheral pulses </li></ul></ul><ul><ul><li>Heart rate </li></ul></ul><ul><ul><li>Temperature and color of skin </li></ul></ul><ul><ul><li>Sensorium </li></ul></ul><ul><ul><li>Pulse pressure </li></ul></ul>
  28. 28. Shock <ul><li>Signs of hemodynamic recovery: </li></ul><ul><ul><li>Slowing of pulse </li></ul></ul><ul><ul><li>Decrease in skin mottling </li></ul></ul><ul><ul><li>Increase in extremity temperature </li></ul></ul><ul><ul><li>Clearing of sensorium </li></ul></ul><ul><ul><li>Urinary output > 1ml/kg/hour </li></ul></ul><ul><ul><li>Increased systolic blood pressure </li></ul></ul>
  29. 29. Abdomen <ul><li>Mechanisms: </li></ul><ul><ul><li>Blunt </li></ul></ul><ul><ul><li>Penetrating </li></ul></ul><ul><li>Spaces: </li></ul><ul><ul><li>Peritoneal cavity </li></ul></ul><ul><ul><li>Pelvis </li></ul></ul><ul><ul><li>Retroperitoneum </li></ul></ul>
  30. 30. Abdomen <ul><li>Physical exam: </li></ul><ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Auscultation </li></ul></ul><ul><ul><li>Percussion </li></ul></ul><ul><ul><li>Palpation </li></ul></ul><ul><ul><li>Evaluate penetrating wounds </li></ul></ul><ul><ul><li>Local exploration of stab wounds </li></ul></ul>
  31. 31. Abdomen <ul><li>Physical exam: </li></ul><ul><ul><li>Assess pelvic stability </li></ul></ul><ul><ul><li>Genital and rectal exam </li></ul></ul><ul><ul><li>Gluteal exam </li></ul></ul>
  32. 32. Abdomen <ul><li>Diagnostic studies: </li></ul><ul><ul><li>CT scan </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>DPL </li></ul></ul><ul><ul><li>Urethrography/cystography </li></ul></ul>
  33. 33. Abdomen <ul><li>Indications for exploration: </li></ul><ul><ul><li>Blunt trauma with instability and positive US or DPL </li></ul></ul><ul><ul><li>Blunt trauma with recurrent hypotension </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Hypotension from penetrating wound </li></ul></ul><ul><ul><li>Bleeding from stomach/rectum/GU (penetrating) </li></ul></ul><ul><ul><li>Gunshot wound </li></ul></ul><ul><ul><li>Evisceration </li></ul></ul>
  34. 34. Abdomen <ul><li>Special considerations: </li></ul><ul><ul><li>Diaphragm </li></ul></ul><ul><ul><li>Duodenum </li></ul></ul><ul><ul><li>Pancreas </li></ul></ul><ul><ul><li>Liver/Spleen </li></ul></ul><ul><ul><li>GU </li></ul></ul><ul><ul><li>Small bowel </li></ul></ul>
  35. 35. Left: Massive hemothorax Right: Chest tube decompression
  36. 36. Tension pneumothorax Chest tube placed and pneumo- thorax resolved
  37. 37. Circulation Heart rate Systolic BP Urine ml/kg/hr Infants 100-160 60 2 Preschool 80-140 80 1.5 School age 80-140 90 1-1.5 Adolescent 60-120 100 0.5-1
  38. 38. Head Trauma <ul><li>500,000 cases per year in US </li></ul><ul><li>10% die prior to hospital </li></ul>
  39. 39. Head Trauma <ul><li>Cerebral Perfusion Pressure </li></ul><ul><ul><li>CPP=MAP-ICP </li></ul></ul><ul><ul><ul><li>MAP =Mean arterial pressure </li></ul></ul></ul><ul><ul><ul><li>ICP = Intracranial pressure </li></ul></ul></ul><ul><li>Cerebral Blood Flow </li></ul><ul><ul><li>50ml/ 100g of brain/minute </li></ul></ul><ul><ul><li><25-EEG activity disappears </li></ul></ul><ul><ul><li>5 – brain death </li></ul></ul>
  40. 40. Head Trauma <ul><li>Mechanism: </li></ul><ul><ul><li>Blunt v. Penetrating </li></ul></ul><ul><li>Severity: </li></ul><ul><ul><li>Mild: GCS 14-15 </li></ul></ul><ul><ul><li>Moderate: GCS 9-13 </li></ul></ul><ul><ul><li>Severe: GCS 3-8 </li></ul></ul><ul><li>Morphology: </li></ul><ul><ul><li>Skull fractures </li></ul></ul><ul><ul><li>Intracranial lesions </li></ul></ul>
  41. 41. Head Trauma <ul><li>Skull fractures: </li></ul><ul><ul><li>Battle’s Sign </li></ul></ul><ul><ul><li>Racoon eyes </li></ul></ul><ul><ul><li>Rhinorrhea/otorrhea </li></ul></ul><ul><ul><li>Linear vault fractures </li></ul></ul><ul><ul><ul><li>400 X risk hematoma in awake patients </li></ul></ul></ul><ul><ul><ul><li>20 X risk in comatose patients </li></ul></ul></ul>
  42. 42. Head Trauma <ul><li>Intracranial lesions </li></ul><ul><ul><li>Epidural hematomas </li></ul></ul><ul><ul><li>Subdural hematomas </li></ul></ul><ul><ul><li>Contusions/hematomas </li></ul></ul><ul><ul><li>Concussion </li></ul></ul><ul><ul><li>Diffuse axonal injuries </li></ul></ul>
  43. 43. Head Trauma <ul><li>Management; </li></ul><ul><ul><li>ABCs! (GCS < 8 intubate patient) </li></ul></ul><ul><ul><li>Hypotension is never presumed to be from head trauma </li></ul></ul><ul><ul><li>CT scan </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><ul><li>Mannitol/lasix </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Barbiturates </li></ul></ul>
  44. 44. Spinal Injuries <ul><li>Level </li></ul><ul><li>Severity </li></ul><ul><li>C-spine-protect always!! </li></ul><ul><ul><li>10% have another vertebral fracture </li></ul></ul><ul><ul><li>Respiratory function may be lost </li></ul></ul><ul><li>Spinal shock </li></ul><ul><li>High dose methylprednisolone in first 8 hours </li></ul><ul><li>Pediatric considerations (SCIWORA) </li></ul><ul><ul><ul><li>SCIWORA – S pinal C ord I njury W ith O ut R adiographic A bnormality </li></ul></ul></ul>
  45. 45. Subluxation C-5 on C-6
  46. 46. Musculoskeletal Injuries <ul><li>May have significant bleeding source </li></ul><ul><li>Evaluate vascular and neurologic status </li></ul><ul><li>Immobilize/traction </li></ul><ul><li>Pelvic fracture </li></ul><ul><ul><li>Stabilize </li></ul></ul><ul><ul><li>Embolize </li></ul></ul>
  47. 47. Musculoskeletal Injuries <ul><li>Crush injuries: </li></ul><ul><ul><li>Myoglobinuria </li></ul></ul><ul><li>Open fractures </li></ul><ul><ul><li>Immobilize </li></ul></ul><ul><ul><li>Antibiotics/tetanus </li></ul></ul>
  48. 48. Musculoskeletal Injuries <ul><li>Compartment Syndrome: </li></ul><ul><ul><li>Pain (especially with passive stretching) </li></ul></ul><ul><ul><li>Paresthesia </li></ul></ul><ul><ul><li>Decreased sensation or function </li></ul></ul><ul><ul><li>Paralysis or loss of pulse are LATE changes and loss of limb is imminent </li></ul></ul><ul><ul><li>Tissue pressures >35-45 mm Hg threaten limb </li></ul></ul>
  49. 49. Cerebral contusion with cerebral swelling and skull fracture
  50. 50. Tear drop fracture anterior C-4
  51. 51. Massive left hemothorax with compressed lung
  52. 52. Tension pneumothorax on right with shifted mediastinum
  53. 53. Fractured vertebral body on CT scan view
  54. 54. Stomach herniated through diaphragm
  55. 55. Epidural hematoma
  56. 56. Massive facial trauma
  57. 57. Contusion of right lobe of liver
  58. 58. Fracture through body of pancreas
  59. 59. Intra-osseous access
  60. 61. Technique for pericardiocentesis
  61. 62. Lap belt abrasion-indicates force of injury and high risk of internal injuries
  62. 63. View of normal vocal cords
  63. 64. Fractured larynx
  64. 65. MRI image of thoracic vertebral fracture and injured spinal cord
  65. 66. Subdural hematoma
  66. 67. Lines of escarotomy in burn injuries

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