This document provides guidance on the acute management of trauma patients. It outlines the following key points: 1) Trauma patients require a systematic approach involving preparation, a primary survey to address life threats (airway, breathing, circulation, disability, exposure), and management of specific injuries. 2) The primary survey follows an ABCDE approach and includes airway management, breathing and ventilation assessment, circulation assessment and intravenous access, disability assessment, and full body exposure/examination. 3) Specific guidance is given for managing potential airway issues, tension pneumothorax, chest trauma, hemorrhage, cardiac injuries, and other concerns uncovered during the primary survey. Checklists, guidelines, and multidisciplinary

1. Acute trauma management
Dr Shambhavi Sharma
1st year Resident

2. Introduction
• Traumatic injuries can range from minor isolated wounds to complex
injuries involving multiple organ systems.
• All trauma patients require a systematic approach to management to
maximize outcomes and reduce the risk of undiscovered injuries.

3. • Breakdowns in the care plan and medical mismanagement typically occur
due to one or more of four potential problems
Communication breakdowns
Failures in situational awareness (eg,failure to perform primary and
secondary survey, failure to recognize shock, failure to anticipate blood
transfusion needs, failure to modify standard management for higher risk
patients)
Staffing or workload distribution problems
Unresolved conflicts

4. Management
• PREPARATION
Pre arrival preparation :
Early notification enables emergency department (ED) staff to do the
following:
• Notify additional personnel (eg, ED staff, trauma surgery, obstetrics,
orthopedics, radiology, interpreter services)
• Assure resources are available (eg, ultrasound, CT, operating room space)
• Prepare for anticipated procedures (eg, tracheal intubation, chest tube)
• Prepare for blood transfusion

5. The primary survey
is organized according to the injuries that pose the most immediate threats to life
Consists of :
• Airway assessment and protection (maintain cervical spine stabilization when
appropriate)
• Breathing and ventilation assessment (maintain adequate oxygenation)
• Circulation assessment (control hemorrhage and maintain adequate end-organ
perfusion)
• Disability assessment (perform basic neurologic evaluation)
• Exposure, with environmental control (undress patient and search everywhere for
possible injury, while preventing hypothermia)

6. Airway management
Airway obstruction is a major cause of death immediately following
trauma
• May be obstructed by the tongue, a foreign body, aspirated material,
tissue edema, or expanding hematoma.

7. • Assessment
Conscious patient:
1. Begin by asking the patient a simple question
A clear accurate response verifies the patient's ability to mentate, phonate, and
to protect their airway, at least temporarily
2. Observe the face, neck, chest, and abdomen for signs of respiratory difficulty,
including tachypnea, accessory or asymmetric muscle use, abnormal patterns
of respiration, and stridor.

8. 3.Inspect the oropharyngeal cavity for disruption; injuries to the teeth or
tongue; blood, vomitus, or pooling secretions.
Note if there are obstacles to the placement of a laryngoscope and
endotracheal tube.
4. Inspect and palpate the anterior neck for lacerations, hemorrhage, crepitus,
swelling, or other signs of injury.
Palpation of the neck also enables identification of the landmarks for
cricothyroidotomy.

9. • In the unconscious patient, the airway must be protected immediately
once any obstructions are removed
indications of endotracheal entubation :
• life-threatening hypoxaemia caused by airway obstruction not relieved
by simple means
• inadequate facemask seal leading to insufficient ventilatory support
• to protect the lower respiratory tract from aspiration of blood or
stomach contents

10. • to preserve the airway from anticipated occlusion by:
oedema
haematoma
displacement of laryngotracheal fracture
• to regulate intracranial pressure by controlling CO2
• to provide a therapeutic ventilatory strategy for hypoxaemia :
flail chest
pulmonary contusion

11. Devices that should be available at the bedside include:
• Suction (ie, multiple pumps and tips)
• Bag-valve mask attached to high flow oxygen
• Oral and nasal airways
• Rescue airways (eg, Laryngeal mask airway)
• Endotracheal tube introducer (ie, gum elastic bougie)
• Video laryngoscope, if available
• Cricothyrotomy kit
• Endotracheal tubes in a range of sizes
• Laryngoscopes, including a range of different sized blades and
handles
•Hard cervical collar

12. checklists improve the efficiency and reduce the complications
associated with airway mangement of trauma patients by around 7%
Smith KA et al Acad Emerg Med. 2015;22(8):989. Epub 2015 Jul 20.

13. Assume that an injury to the cervical spine has occurred in all blunt
trauma patients until proven otherwise.
patients with isolated penetrating trauma, no secondary blunt injury,
and an intact neurologic examination typically do not have an
unstable spinal column injury
Routine spinal immobilization is not recommended following
penetrating injury, and has been demonstrated to be associated with
increased mortality
Application of a cervical collar

14. • The anterior portion of the cervical collar should be temporarily
removed and manual in-line stabilization maintained for all patients with
blunt traumatic injuries receiving airway interventions, including bag-
mask ventilation

15. Management in c-spine injuries
• Almost all airway maneuvers, including jaw thrust, chin lift, head tilt,
and oral airway placement, result in some degree of C-spine
movement.
• To secure the airway with direct laryngoscopy, manual in-line
stabilization (MILS) of the neck is the standard care of these patients
in the acute stage.

16. • Manual in-line immobilization (MILI)
• maneuver that applies forces to the head and neck to offset any
applied forces to the spine that occur during airway management
• There should not be additional forces applied that result in axial
traction, with the overall goal of keeping the head and neck in the
same position during laryngoscopy.

17. • MILS is best accomplished by having two operators in addition to the
physician who is actually managing the airway.
• The first operator stabilizes and aligns the head in neutral position
without applying cephalad traction.
• The second operator stabilizes both shoulders by holding them
against the table or stretcher.
• The anterior portion of the hard collar, which limits mouth opening,
may be removed after immobilization.

18. • Other measures and techniques:
• including the McCoy laryngoscope, rigid fiberoptic video
laryngoscope
• cricothyroidotomy

19. Breathing and ventilation — Once airway patency is ensured, assess
the adequacy of oxygenation and ventilation
Chest trauma accounts for 20 to 25 percent of trauma-related deaths,
in large part due to its harmful effects on oxygenation and ventilation

20. • Assessment :
• inspect the chest wall looking for signs of injury, including asymmetric
or paradoxical movement (eg, flail chest),
• auscultate breath sounds at the apices and axillae,
• and palpate for crepitus and deformity.
• In unstable patients, obtain a portable chest radiograph.
• Tension pneumothorax, massive hemothorax, and cardiac
tamponade impose immediate threats life
• Ultrasound can provide important information about all these
diagnoses during this portion of the assessment.

21. FAST Scan in chest trauma

22. Chest trauma

23. • 75% patients with thoracic trauma can be managed expectantly
• However, thoracic injury is a contributing factor in 75% of all trauma
related deaths

24. • All hemodynamically stable patients with suspected chest trauma
should undergo chest x ray
• Further diagnostics and management vary for penetrating and blunt
chest trauma

25. Penetrating thoracic injuries
• Chest wall injury
• Low velocity: stab wounds, may involve intercostal artery laceration
• High velocity: gunshot wounds, more significant chest wall injury
• Pain control, local wound care, pulmonary mechanical support

26. Open pneumothorax
• Soft tissue defect ≥2/3 circumference of trachea
• Air entrainment into pleural space due to negative intrathoracic pressure
during inspiration
• Managed with supplemental oxygen, intubation when oxygenation or
ventilation inadequate
• Definitive treatment with chest tube placement
• Occlusive dressing taped on three sides to create a flap valve effect used as
temporizing measure

27. Lung injuries
Pneumothorax and hemothorax
• Hemothorax is assumed in presence of traumatic pneumothorax
• Managed with 32 to 36Fr tube thoracostomy
• Mechanical ventilation may be necessary if difficulty oxygenating or
ventilating

28. Tension pneumothorax
• Clinically unstable patient with chest trauma: high degree of suspicion
for tension pneumothorax
• Progressive accumulation of air pressurizes pleural caity pushing
mediastinum to opposite side
• Patient can rapidly develop obstructive shock, with precipitous fall in
blood pressure, and cardiac arrest with PEAs

29. • Circulation
• While circulation is assessed, two large-bore (16 gauge or larger)
intravenous (IV) catheters are placed,
• most often in the antecubital fossa of each arm, and blood is drawn
for testing, particularly for blood typing and crossmatch.
• Intraosseous cannulation or central venous catheter placement
(ideally under ultrasound guidance) can be performed

30. Hemorrhage

31. Shock may exist even in the setting of "normal" vital signs
• patients on cardioactive medications such as beta blockers
• Young patients without underlying comorbidities
• A bradycardic response to penetrating intraperitoneal injury, may be
vagally mediated

33. • DYNAMIC” MEASURES OF INTRAVASCULAR VOLUME
CVP change to fluid challenge
IVC/SVC Caliber changes in response to breathing
Stroke Volume Variation (SVV)
Pulse Pressure Variation (PPV)
Dynamic Changes in Aortic Flow Velocity/Stroke Volume Assessed by
Echocardiography

34. • The passive leg-raising test
• PLR is based on the principle that it can induce an abrupt increase in
venous return secondary to auto-transfusion of peripheral blood from
capacitive veins of the lower part of the body
•

36. • Disability
Glasgow Coma Scale (GCS) score,
assessments of pupillary size
reactivity
gross motor function
sensation

38. • Exposure
completely undressed and that his or her entire body is examined for signs
of injury during the primary survey
Missed injuries pose a grave threat
Regions often neglected include the scalp, axillary folds, perineum, and in
obese patients,
abdominal folds.
• Penetrating wounds may be present anywhere.

39. • While maintaining cervical spine precautions, examine the patient's
back; do not neglect examination of the gluteal fold and posterior
scalp.

40. Chest trauma

41. • 75% patients with thoracic trauma can be managed expectantly
• However, thoracic injury is a contributing factor in 75% of all trauma
related deaths

42. • All hemodynamically stable patients with suspected chest trauma
should undergo chest x ray
• Further diagnostics and management vary for penetrating and blunt
chest trauma

43. Penetrating thoracic injuries
• Chest wall injury
• Low velocity: stab wounds, may involve intercostal artery laceration
• High velocity: gunshot wounds, more significant chest wall injury
• Pain control, local wound care, pulmonary mechanical support

44. Open pneumothorax
• Soft tissue defect ≥2/3 circumference of trachea
• Air entrainment into pleural space due to negative intrathoracic pressure
during inspiration
• Managed with supplemental oxygen, intubation when oxygenation or
ventilation inadequate
• Definitive treatment with chest tube placement
• Occlusive dressing taped on three sides to create a flap valve effect used as
temporizing measure

45. Lung injuries
Pneumothorax and hemothorax
• Hemothorax is assumed in presence of traumatic pneumothorax
• Managed with 32 to 36Fr tube thoracostomy
• Mechanical ventilation may be necessary if difficulty oxygenating or
ventilating

46. Tension pneumothorax
• Clinically unstable patient with chest trauma: high degree of suspicion
for tension pneumothorax
• Progressive accumulation of air pressurizes pleural caity pushing
mediastinum to opposite side
• Patient can rapidly develop obstructive shock, with precipitous fall in
blood pressure, and cardiac arrest with PEAs

47. Clinical signs of tension pneumothorax
• Tachycardia
• Tachypnea
• Hypoxia
• Hypotension refractory to fluids
• Hyper expanded chest
• Hyperresonant percussion notes
• Increased JVP/CVP
• Increased airway pressure

48. Heart and great vessels
• Over 80% of patients suffering trauma to heart and great vessels
expire on site
• Cardiac injury usually occurs through anterior chest injury between
the midclavicular lines
• Right ventricle is most commonly involved
• Atrial injuries less common and less severe unless multi chamber
injury occurs

49. • Pericardial tamponade suspected if patient has distended neck veins,
muffled heart sounds and signs of shock(Beck’s triad)
• Even 50mL in pericardial sac can cause tamponade

50. Diagnosis
• Transesophageal echocardiography is diagnostic modality of choice in
hemodynamically stable patients
• FAST scan and transthoracic echo can also identify cardiac injury
• Presence of pericardial fluid on echo: emergent operative exploration
• Subxiphoid pericardial exploration in case of multiple injuries
requiring emergent intervention

51. Subxiphoid pericardial exploration
• Performed under G.A
• Diaphragm exposed via subxiphoid approach and longitudinal incision
made to expose pericardium
• 1 cm longitudinal incision given on pericardium to drain fluid
• Straw colored: negative examination
• Blood: definitive exploration and cardiorrhaphy

52. Diaphragmatic injuries
• 31% may not have abdominal tenderness
• 40% have normal chest x rays
• Undiagnosed diaphragmatic injury associated with high risk of bowel
herniation
• Primary repair done with non absorbable horizontal mattress sutures

53. Aerodigestive system
• Associated with subcutaneous emphysema along with visible air fluid
levels in chest x ray
• Tracheobronchial injury:
• securing airway is first priority
• Fibreoptic bronchoscopy to evaluate injury
• Esophageal injury:
• Secondary mediastinitis associated with very high mortality
• Esophagoscopy to assess mucosal injury
• Esophagography with aqueous contrast followed by barium can rule out
esophageal injury

54. Blunt thoracic injuries
• 40-50% of all motorvehicle accidents associated with blunt thoracic
injuries
• Use of bedside ultrasound can help diagnose pneumothorax with
greater accuracy than traditional upright chest x ray
• Chest x ray and CT scan

55. Chest wall injury
• Chest wall or rib contusion/fracture
• Flail chest involves fracture of multiple ribs at multiple places
separating a segment which moves independently from chest wall
• Underlying pulmonary contusion in flail chest can lead to respiratory
compromise
• Early placement of epidural catheter can help prevent respiratory
insufficiency and pneumonia

56. • Surgical internal fixation of ribs is a newer technique which can
reduce ventilator requirement and enhance recovery