This document discusses the initial assessment and intensive care of trauma patients. It covers the trimodal distribution of trauma deaths, the importance of the "golden hour" period, and the steps of the primary and secondary surveys using the ABCDE approach. The primary survey involves assessing the airway, breathing, circulation, disability, and exposure. Key points include techniques for airway management and control of hemorrhage. Overall it provides an overview of the critical principles and processes for stabilizing trauma patients in the initial emergency period.

1. INITIAL ASSESSMENT AND INTENSIVE CARE INTRAUMA
S Mahima
Department of Oral and Maxillofacial Surgery

2. CONTENTS
• INTRODUCTION
• TRIMODAL DISTRIBUTION
• GOLDEN HOUR
• PREPARATION
• TRIAGE
• BASIC LIFE SUPPORT
• A B C D E
• SECONDARY SURVEY
• DIAGNOSIS OF MAXILLOFACIAL INJURIES

3. INTRODUCTION
• Trauma annually affects hundreds of thousands of
individuals, costs country billions in direct expenditure,
indirect losses
• Trauma care - drastically improved in last few decades -
improvements in trauma system, emergency care,
resuscitation, triage
• Maxillofacial trauma - injury to facial soft tissue, bone
• Commonly associated with multiple system injuries
• Most common mechanisms -blunt or crush injuries
caused by RTA or assault
• Successful management - begins with immediate
application of principles of BLS/ALS
• Goal of initial emergency care - recognize life
threatening injuries, provide life saving, supportive
measures until definitive care can be achieved

4. TRIMODAL DISTRIBUTION
• Deaths from trauma follow a trimodal distribution
• 1st peak - 40% - 50% trauma deaths -
immediately or within minutes of accident, due to
lacerations of brain, brainstem, high spinal cord,
heart, aorta, other large blood vessels
• 2nd peak - 30 % trauma related death (mins -
hour) - due to hypoxia, hypovolemic shock as
result of severe chest injuries, abdominal trauma
with ruptured spleen or liver, orthopaedic injuries
such as fractured pelvis, long bones associated
with significant blood loss - GOLDEN HOUR
• 3rd peak - (hours - days) - multiple organ failure,
sepsis, distress

5. GOLDEN HOUR
• Time is of the essence in caring for patients with multiple
injuries - critical period immediately following injury -
historically termed - golden hour
• Mortality - estimated to be approximately 60% - high
mortality rate - inadequate assessment, resuscitation
• To minimize morbidity, mortality - appropriate,
aggressive initial care
• Patient outcome - directly related to time from injury to
definitive care
• Rapid assessment of injuries, institution of life-preserving
measures – helped reduce preventable death rate of 35%
to <10%

6. Lack of a systematic approach to initial assessment - errors
from which resuscitation team, ultimately patient, do not
recover
Initial assessment and management includes -
• Preparation
•Triage
• Primary survey (ABCDEs)
• Resuscitation
• Adjuncts to the primary survey and resuscitation
• Consideration of need for transfer
• Secondary survey (more detailed evaluation, diagnosis,
treatment)
• Adjuncts to secondary survey
• Continued post-resuscitation monitoring, reevaluation
• Definitive care

7. PREPARATION
PRE-HOSPITAL PHASE
• Occurs before patient involvement,
concerns establishment of protocols aimed
at directing safe transport of right patient to
appropriate trauma center at earliest
possible time using ideal transport method
• Treatment goals - maintenance of airway,
control of external bleeding and shock,
patient immobilization, transport to closest
appropriate facility, preferably a trauma
center
• In addition - information concerning
mechanism of injury, related events, past
medical history of patient - receiving team -
possibility of particular injuries, their severity
to enable faster diagnosis, treatment

8. HOSPITAL PHASE -TRIAGE
A method of quickly identifying victims who have life-threatening injuries and who have the best
chance of surviving.
AIMS OFTRIAGE
• To ensure that patients are treated in the order of their clinical urgency
• To ensure that treatment is done appropriately and timely
• To allocate the patient to the most appropriate assessment and treatment area.
• To provide ongoing assessment of patients
• To provide information to patients and families regarding services expected care and waiting times

9. TYPES OFTRIAGE
SIMPLETRIAGE
• Simple triage is usually used in a scene of an accident or
"mass-casualty incident" (MCI)
• In order to sort patients into those who need critical attention,
immediate transport to hospital and those with less serious
injuries
• Include triage tag - prefabricated label placed on each patient
that serves to accomplish several objectives
Identify the patient.
Bear record of assessment findings.
Identify priority of patients’ need for medical treatment,
transport from emergency scene
Track patients' progress through triage process
Identify additional hazards such as contamination

11. ADVANCED TRIAGE
• Seriously injured people - not receive advanced care because they are unlikely to survive
• Medical resources available - not sufficient to treat all people who need help
• Followed during - terrorist attacks, mass shootings, volcanic eruptions, earthquakes
REVERSETRIAGE
• Usually triage - prioritizing admission
• Applied to discharging patients early when medical system is stressed
• This process - reverse triage
• To accommodate a greater number of new critical patients - existing patients may be triaged
hence can be discharged

12. ADULT BLS ALGORITHM
BASIC LIFE SUPPORT

14. The AHA’s BLS 2015 (American Heart Association) Guidelines - Update for CPR and Emergency
Cardiovascular Care (ECC)
• In adult victims of cardiac arrest - reasonable to perform chest compression at
 Rate – 60/min
 Compression depth -2 - 2.4 inches or 5cm for an average adult (beyond causes rib
fracture)
- Infants - 1.5-2in
 Sequence - Change of traditional ABC to CAB
 Ratio - 30 chest compression to two rescue breaths
 Look Listen and feel for breathing is no longer recommended (Instead of assessing
persons breathing - begin CPR)

15. A B C D E
• A: Airway with cervical spine control
• B: Breathing and ventilation
• C: Circulation and haemorrhage control
• D: Disability (neurological status)
• E: Exposure + environment
• F: Frequent reassessment

16. AIRWAY MAINTENANCEWITH CERVICAL SPINE CONTROL
• Inability to protect the airway is a leading cause of preventable deaths following injury
• Urgent airway interventions is required in patients with - direct upper airway trauma, severe upper
airway burns, severe traumatic brain injury
• Suspect cervical spine injury in all patients unless otherwise proven
• High chance in high speed impact, patients with altered consciousness
• 15% patients with supraclavicular injuries, 5 % with head injury
• Stabilization by cervical collar, bindings , backboards or head immobilizers
• Semirigid or flexible avoided

17. CAUSES OF AIRWAY OBSTRUCTION
• Tongue position
• Aspiration of foreign bodies, regurgitation of stomach contents
• Facial, mandibular, tracheal and/or laryngeal fractures
• Bleeding (retropharyngeal hematoma resulting from cervical spine fractures)
• Traumatic brain injury

18. SYSTEMATIC APPROACH FOR AIRWAY MANAGEMENT
• Assess the airway - recognize obstruction
• Clear the airway
• Reposition the patient - perform simple airway maneuvers to ensure air flow into the airway
• Utilize artificial airway
• Perform endotracheal intubation
• Cricothyroidotomy
• Tracheostomy

19. ASSESSING AIRWAY OBSTRUCTION
• A traditional “look, listen and feel” can generally identify airway
• Look - Cyanosed, confused
• Listen - Stridor, hoareseness of voice
• Feel - Movement of air on inspiration and expiration

20. MALLAMPATI CLASSIFICATION
Class I: tonsillar pillars and all of uvula
Class II: more than base of uvula but not pillars
Class III: only base of uvula
Class IV: no uvula or soft palate

21. PATILTEST
• It involves measuring the distance between the thyroid notch and tip of the jaw -
thyromental gap
• Thyromental gap < 6cm - Difficult airway
6-6.5 - Might be less difficult
>6cm - Normal airway

22. CLEARTHE AIRWAY
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 or with suction
Fingers of one hand maintain open mouth while fingers of other hand sweep
through oral cavity removing any foreign material

23. REPOSITIONTHE PATIENT
CHIN LIFT - Mandible is gently
lifted upward using the fingers of
one hand placed under the chin -
thumb of the same hand lightly
depresses the lower lip to open the
mouth
JAWTHRUST - knuckles of the
index fingers are placed behind
angle of mandible with thumb -
apply pressure on cheek bones at
same time - lifts and displaces
mandible forward
breathing spontaneously - high-
flow oxygen via the facemask
not breathing - facemask with a
bag-valve device (AMBU bag) and
is continuously bagged
Jaw thrust
Fingers of one hand grasp the anteroinferior
border of the mandible and thumb on the lingual
surface of lower incisors chin is gently lifted
Grasping the angle of the
mandible and elevating the
jaw anteriorly
Chin lift

25. ARTIFICIAL AIRWAY
OROPHARYNGEAL AIRWAY
• OPA should extend from the corner of the mouth to the ear lobe
• Introduced upside down so that its concavity is directed upward, until the soft
palate
• The device is rotated 180 degrees to direct the concavity down and the airway
is slipped into place over the tongue
INDICATION
• Used to maintain a patent airway only on deeply unresponsive patients
• No gag reflex

26. Inserted in the nostril that appears to be unobstructed - passed gently into the posterior oropharynx
- Approximate distance between the end of the patient’s nose and the ear lobe
Indication
• Used on patients who are unable to tolerate an OPA or is not fully responsive
• Gag reflex
Contraindication
• Do not use on suspected basilar skull fracture
NASOPHARYNGEAL AIRWAY (NPA)

27. Indications
- Maintenance of patent airway and non
invasive method are unsuccessful
- Airway needs to be protected from
aspiration of blood or gastric content
- Positive pressure ventilation
- Possibility of future tracheostomy
Contraindications
- Cervical spine injury
- CSF rhinorrhea
- Fracture anterior cranial fossa
- Retropharyngeal swelling
- Fractured larynx
PERFORM ENDOTRACHEAL INTUBATION

28. CRICOTHYROIDOTOMY
Refers to creation of a communication between airway and skin via the cricothyroid membrane
1. Needle cricothyroidotomy
2. Open or percutaneous cricothyroidotomy technique
Indications
1. Maxillofacial trauma - obstruction of airway from massive facial trauma
2. Oropharyngeal obstruction - edema secondary to infection ,allergic reaction, foreign body
3. Oral and nasal intubation is contraindicated (congenital malformation, massive hemorrhage)
4. Spinal cord injury
Contraindications
1. Inability to identify surface landmarks (thyroid cartilage, cricoid, cricothyroid membrane) due to e.g. obesity,
cervical trauma
2. Airway obstruction distal to subglottis e.g. tracheal stenosis or transection
3. Laryngeal cancer: Other than for an extreme airway emergency, avoid a cricothyroidotomy so as not to seed the
soft tissue of the neck with cancer cells
4. Age: Contraindicated in children under 12 years
5. Direct injury to larynx

29. PROCEDURE
• Needle cricothyroidotomy using a 12 or 14- gauge
cannula
• Position the patient supine with neck exposed and
extended (if possible)
• Identify surface landmarks i.e. thyroid cartilage,
cricoid cartilage and cricothyroid membrane
• Prepare a sterile field
• Inject 1% lidocaine with 1:100 000 epinephrine into
the skin (anaesthetise the airway and suppress the
cough reflex)

30. • Fix the thyroid cartilage with the 1st & 3rd fingers of the non-dominant hand leaving the 2nd finger free to
locate the cricothyroid membrane
• With the dominant hand, pass a 14- gauge intravenous cannula attached to a syringe filled with normal
saline, through the cricothyroid membrane, directing it caudally at 45degree bending the distal part of the
needle can assist with directing the catheter along the tracheal lumen
• Apply negative pressure to the syringe as the needle is advanced.Air bubbles will appear in the fluid-filled
syringe as the needle traverses the membrane and enters the trachea
• Advance the cannula and then retract the needle.
• Attach jet ventilation and ventilate at 15 L/min 10.
• Judge the adequacy of ventilation by movement of the chest wall and
auscultation for breath sounds, and by pulse oximetry

31. SURGICAL CRICOTHYROIDOTOMY
• Position the patient supine with anterior neck exposed and extended (if possible)
• Identify the surface landmarks i.e. thyroid cartilage, cricoid cartilage and cricothyroid membrane
• Prepare a sterile field
• Inject 1% lidocaine with 1:100 000 epinephrine into the skin, soft tissue and through the cricothyroid
membrane into the airway to anaesthetise the airway
• Fix the thyroid cartilage with the 1st and 3rd fingers of the non-dominant paplate cricothyroid membrane

32. • Make a 2cm transverse incision through the cricothyroid membrane along the superior edge of the cricoid ( in
order to avoid the anastomosis of superior thyroid and cricoid artery) angling the scalpel cephalad so as to avoid
injuring the vocal cords; await a distinct “pop” sensation as the scalpel pierces through the membrane and enters
the larynx
• Dilate the tract by passing a curved haemostat through the incision, angling it caudad through the cricoid ring
and along the trachea taking care not to perforate the posterior wall of the trachea
• Insert a tracheostomy or endotracheal tube

33. TRACHEOSTOMY
• Greek origin: ‘stom’ - ‘mouth’
• Creation of a stoma between trachea and cervical skin
INDICATION
• Pediatric patients
• Laryngeal fracture
• Tracheal transection
• Laryngeal foreign body
• Subglottic stenosis
• Prolonged ventilation
CONTRAINDICATION
• Expanding hematoma in the neck
• When cricothyrotomy can be done
safely
• Lack of experience
• Cervical trauma

34. Patient correctly
positioned with shoulder pad
and head ring

35. 4 to 5cm incision approx. 2cm below cricoid
cartilage carried through skin , subcutaneous
tissue, platysma
Deep cervical fascia is identifiable

36. Blunt dissection , infrahyoid facia over
sternohyoid can be seen ( frequent
palpation and bluntly spreading tissue
vertically in the midline toward trachea
prevent injury to major vessels
Retraction of exposed pretracheal fascia
and thyroid isthmus (inorder to mobilise
the thyroid isthmus cut the suspensory
ligament at the inferior border(Ushape
,Tshape)

37. The tracheal rings are clearly seen with the
cricoid cartilage superiorly

39. BREATHING &VENTILATION
Once the airway has been secured, breathing and ventilation must be assessed
Serious chest injuries that compromise ventilation are as follows -
• A: Airway obstruction
• T:Tension pneumothorax
• O: Open pneumothorax
• M: Massive haemothorax
• F: Flail chest

40. ASSESSMENT OF BREATHING
• After establishing an airway your next step should be to assess breathing
• Look
Breathing pattern regular or irregular
Nasal flaring
Adequate expansion, retractions
• Listen
Shortness of breath when speaking
Unresponsive place ear next to patients mouth
Is there any movement of air?
• Feel
Check the volume of breathing by placing you ear and cheek next to the patient’s mouth
• Normal rate - Adult 12 - 20/min, Child 15 - 30/min, Infant 25 - 50/min
• Rhythm - Regular, Irregular

41. Acute blood loss resulting in hypovolemic shock is responsible for 30% to 40% of trauma deaths
Prompt control of post traumatic bleeding is a must
• Initial digital compression should be given to control the bleeding
• 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
• 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
CIRCULATION AND HAEMORRHAGE CONTROL

42. METHOD OF INSERTION OF A POST-NASAL 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

43. AMERICAN COLLEGE OF SURGEONS (2001), Classification of acute
hemorrhage Committee

44. • The initial intravenous resuscitation fluid used in most hospitals is a balanced
electrolyte solution such as lactated Ringer’s solution or 0.9% normal saline
• Initially, the patient should be given 2L of intravenous fluid rapidly over 10 to 15
minutes and then observed
• If this maneuver does not raise the systolic blood pressure to at least 80 to 100 mm
Hg, the patient requires additional fluid, blood, and control of blood loss
• If the patient does not respond to initial fluid resuscitation and blood transfusions,
either surgical intervention is required to control continued hemorrhage or the
initial diagnosis of hypovolemia is incorrect

46. EXPOSURE AND ENVIRONMENTAL CONTROL
• The patient should be completely disrobed so that all of the body can be visualized,
palpated, and examined for injuries or bleeding sites.
• Patient should be kept warm during this stage

47. PHYSICAL EXAMINATION

48. DISABILITY ASSESSMENT OF NEUROLOGICAL DEFICIT
Patient score determines category of neurological impairment
• Score 15= Normal
• Score 13 or 14 = Mild injury
• Score 9-12 = Moderate injury
• Score 3-8 = Severe injury

49. ROLE OF INTRACRANIAL PRESSURE
• 10 mmHg - Normal
• > 20mmHg - Abnormal
• > 40mmHg - Severe
•  ICP - deteriorates brain function - poor outcome
SYMPTOMS & SIGNS OF INCREASED ICP
• Diminishing level of consciousness
• Headache, vomiting, seizures
• Cushing’sTriad – bradycardia, hypertension, abnormal respiration
• Pupillary changes
• Papilledema

50. MEDICALTHERAPIES FOR HEAD INJURY
• Head end elevation - 30 deg
• Intravenous fluids
• Maintain normovolemia
• Hypotonic/glucose containing fluids should not be used
• Serum sodium levels monitored daily
MANNITOL
0.25-1g/kg
Osmotic agent- dec ICP, maintains brain
metabolism
Dec ICP within 6 hrs.
Expands volume, O2 carrying capacity.
Diuretic effect- net intravascular volume is
reduced
FRUSEMIDE
To reduce ICP in conjunction with mannitol
Dose 0.3 to 0.5 mg/kg
Never use in Hypovolemia

51. CEREBROSPINAL FLUID (CSF)
• CSF is a clear, colorless body fluid found in the brain and spine
• Produced in the choroid plexuses of the ventricles of the brain
• Occupies the subarachnoid space
• Brain produces roughly 500ml of CSF per day, this fluid is constantly reabsorbed, so that only 100-
160 ml is present at any one time
CSF RHINORRHOEHA
• cribriform plate or ethmoid sinus roof into the nose - fracture site is the posterior wall of the
frontal sinus through which CSF can escape into the nose via the nasofrontal duct - Less common
are middle cranial fossa fractures that can cause leakage to the nose via the sphenoid sinus

52. CSF OTORRHOEA
Defined as leakage of CSF from subarachnoid space into the middle ear cavity or mastoid air
cells
CAUSES
• Labyrinthine malformation
• Congenital
• Abnormal development of facial canal
• Bony and dural defects along the temporal bone
• Iatrogenic
• Aberrantly distributed arachnoid granulations
• Infection
• Traumatic
• most associated with transverse fracture of temporal bone

53. DIAGNOSIS OF MAXILLOFACIAL INJURIES
• Inspection
• Palpation
• Diagnostic Imaging
INSPECTION
• Hemorrhage
• Otorrhea
• Rhinorrhea
• Contour deformity
• Ecchymosis
• Edema
• Continuity defects
• Malocclusion
PALPATION
• “Step” Defect
• Crepitus
• Bony segments
• Subcutaneous emphysema
• Mobility
DIAGNOSTIC IMAGING
• Panorex
• CT

54. ORBITAL FRACTURE
• Periorbital edema and ecchymosis
• Diplopia
• Subconjunctival hemorrhage
• Lid lacerations
• Increased intercanthal distance
• Epiphora
• Prompt Ophthamology consult

55. Orbital emphysema ( eye brow sign ) Occasionally a 'tripod' or
'blowout' fracture will cause a leak of air from the maxillary
antrum into the orbit.This can have the appearance of a dark
'eyebrow'

56. LeFORT I
• Maxilla displaced posteriorly and inferiorly
• Open bite deformity
• Hypoesthesia of infraorbital nerve
• Malocclusion
• Mobility of maxilla
• Noted by grasping maxillary incisors

57. LeFORT II AND III
• Bilateral periorbital edema & ecchymosis
• Step deformity palpated infraorbital & nasofrontal area
• CSF rhinorrhea
• Epistaxis

58. NASAL FRACTURES
• Depression or angulation
• Periorbital ecchymosis
• Epistaxis
• Tenderness
• Crepitus
• Septal deviation
• Septal hematoma

59. MANDIBULAR FRACTURES
• Tenderness & pain
• Malocclusion
• Ecchymosis in floor of mouth
• Mucosal lacerations
• Step defects inferior border
• CNV3 Disturbances

61. REFERENCES
• Peter Ward Booth, Barry L. Eppley, Rainer Schmelzeisen. Maxillofacial Trauma and Esthetic Facial Reconstruction 11th edition
• Oral and MaxillofacialTrauma,Volume 2. Raymond J. Fonseca,RobertV. Walke r
• Williams J. L., & Rowe, N. L. (1994). Rowe andWilliams' maxillofacial injuries
• Bailey & Love’s short practice of surgery, 25th edn
• Resuscitative strategies in traumatic hemorrhagic shock , bouglé et al. Annals of intensive care 2013
• Emergency & Critical Care Pocket GuideACLSVersion, Eighth Edition
• Advanced trauma life support student manual. 6th ed
• Initial Assessment and Evaluation ofTraumatic Facial Injuries -Tuan A.Truong
• Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach - Michal Barak
• Guidelines for essential trauma care -World Health Organization
• Resident Manual ofTrauma to the Face, Head, and Neck - First Edition
• Trauma - Seventh Edition - Kenneth L. Mattox, Feliciano, Ernest E