The document discusses management of trauma patients. It covers the key steps in the golden hour including airway management, breathing, circulation, disability assessment and exposure. It details approaches to airway control including adjuncts like oropharyngeal and nasopharyngeal airways. Signs of life-threatening thoracic injuries like tension pneumothorax are outlined. Treatment of hemorrhagic shock focuses on stopping blood loss, restoring perfusion and minimizing contamination through fluid resuscitation and hemorrhage control.

1. Swapnil Sachan
D.J college of dental sciences
PG 3rd Year

2. 
 Golden hour
 ABCDEF
 Airway management
 Shock management
 AMPLE history
Contents

3. 
Incidence

4. 
Time And Tide Waits For None

5.  AR Cowley
 The First Hour following a trauma during which aggressive
resuscitation can improve the chances of survival and
restore the normal functions.
 Early pre-hospital care, early transport, aggressive
resuscitation and interventions
Golden Hour

6. 
“The Platinum Ten Minutes”
Platinum Minutes

7. 
 Severe -5% of all injuries, but more than 50% of all
trauma deaths
 Urgent - 10% to 15%
 Non Urgent – 80 %
Three Categories

8. 
1. Preparation and transport
2. Primary survey and resuscitation, including monitoring
and radiography
3. Secondary survey, including special investigations,such
as CT scanning or angiography
4. Re-evaluation
5. Definitive care
Assessment Principles – American College Of
Surgeons

9. 
 The trauma ambulance and paramedics
 Convey the status and number of victims to the
hospital
 Provide on site care
 ventilation and spine stabilization
Pre-Hospital Phase

10. 
 Pneumatic anti-shock garments and the
establishment of intravenous lines
 administration of fluid should be reserved for
transport times greater than 30 minutes or patients
bleeding in excess of 50 mL per minute.
 Long bone fracture – traction splint

11. 
 No. of patients and the severity of their injuries do
not exceed the ability of the facility to provide care.
 MASS CASUALTIES
 The no. of patients and the severity of their injuries
exceed the ability of the facility to provide care.
Multiple Casualties

12. 
 A method of quickly identifying victims who have
immediately life-threatening injuries AND who have
the best chance of surviving.
Triage

13. 
 Simple Triage And Rapid Transport
 respiratory status, perfusion status, and mental status
 "immediate," "delayed," or "minor" category
Start System

14. 
Hospital Phase

15. 
 A - Airway (with C-spine precautions)
 B – Breathing and ventilation
 C – Circulation and hemorrhage control
 D – Disability + neurological status
 E – Exposure + environment
 F - Frequent re-assessment
Primary Survey

16. 
 Suspect cervical spine injury in all patients unless other
vise proven
 High chance in high speed impact, and in patients with
altered consciousness
 15% patients with supraclavicular injuries and 5 % with
head injury
Airway Maintenance With Cervical
Spine Control

17. 
 Hyper-extension or hyper-flexion of
the patient’s neck should be avoided
 Cervical collars or neck support
 Neuronal deficit and paralysis
 SUSPECT,PROTECT& DETECT
Cervical Spine Control

18. 
 As a general rule – if patient talks properly  airway is
patent (A)  breathing is adequate (B) sufficient
delivery of oxygen through circulation (C) to transport
the oxygen to the brain (D)
Assessment Of Airway

19. 
Look
 Agitated or obtunded.
 Agitation suggests hypoxia, and obtundation
suggests hypercarbia.
 Pattern of breathing and use of accessory muscles of
ventilation.
Look , Listen and Feel

20. 
 Abnormal sounds.
 Noisy breathing, Snoring, gurgling - partial
obstruction of the pharynx or larynx.
 Hoarseness - laryngeal obstruction.
 Abusive patient -hypoxic
Listen

21. 
 location of the trachea and determine whether it is in
the midline
 foreign objects (e.g.,fractured teeth, fillings,
dentures) should be removed.
Feel

22. 
 Tongue fall
 Aspiration of foreign bodies
 Regurgitation of stomach contents
 Facial, mandibular, tracheal and laryngeal fractures
 Retropharyngeal hematoma resulting from cervical
spine fractures
 Traumatic brain injury
Reasons For Airway Obstruction

23. 
Jaw Thrust Procedure

24. 
 Mandible is gently lifted upward using the fingers of one
hand placed under the chin. The thumb of the same hand
lightly depresses the lower lip to open the mouth.
Chin Lift Procedure

25. 
 suction should be used to clear any secretions
 nasogastric tube or soft suction catheter may be
used in patients without suspected midface or
cranial base - tubes inadvertently passed into the
cranial vault.
 oral or nasal airway - keep the airway patent
 nasal airway is better tolerated in an awake patient.

26. 
 Supra-glottic
 Infra-glottic
Airway Devices

27. 
 OPA should extend from the corner
of the mouth to the angle of the
mandible.
 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
Oropharyngeal Airway

28. 
28

29. 
 inserted in the nostril that appears to be unobstructed
 and passed gently into the posterior oropharynx
 approximate distance between the end of the patient’s
nose and the ear lobe
Nasopharyngeal Airway

30. 
30

31. 
31

32. 
 if oro-tracheal intubation has failed or bag-mask
ventilation is not maintaining sufficient oxygenation
 No cuff – chances of gastric distension and aspiration
Laryngeal Mask Airway

33. 
 two tubes - occlusion of the esophagus to reduce the
risk of aspiration.
 does not have a cuffed tube in the trachea -not a
definitive airway
Multilumen Esophageal Airway

34. 

35. 
 neck swelling, dyspnea, voice alteration, or frothy
hemorrhage
 tenderness, and laryngeal or tracheal crepitus
 Endotracheal intubation / surgical airway
Injuries To The Larynx And Trachea

36. 
 Defined as an inflated cuffed tube in the trachea for the
longer patency period.
 Orotracheal
 Naso tracheal
 Contraindicated - frontal sinus fractures, base of skull fractures,
and ant cranial fossa fractures
 Surgical
Definitive Airway

37. 
Indications

38. 
 ability to maintain a patent airway in a less invasive
manner
Contraindications

39. 
LEMON

40. 
40
Oral & Maxillofacial trauma – Fonseca Walker

41. 
 Preparation
 Pre oxygenation
 Pre medication
 Paralysing
 Pressure (Cricoid)
 Placement
 Position
 Post intubation care
7 Ps

42. 
 L: Lidocaine
 O: Opioids (typically fentanyl)
 A: Atropine
 D: Defasciculating agent
Premedication - LOAD

43. 
 flexion of the neck, to align the
pharyngeal and laryngeal axes.
 head is extended at the atlanto-
occipital joint so that the oral axis is
in line with the other two
Laryngoscopy

44. 
Complications

45. 

46. 
Needle Cricothyroidotomy
 Insertion of a wide-bore needle (or IV cannula) via
the crico-thyroid membrane into the airway
 Intermittent insufflation (1 second on and 4 seconds
off)
 Maximum 30-45 minutess
 Inadequate ventilation
Surgical Airway

47. 

48. 
48

49. 
49

50. 
Surgical Cricothyroidotomy

51. 
 3 cm long skin incision
 Cut down through the cricothyroid membrane
 tracheal dilator is inserted to open up the incision,
separating the thyroid and cricoid cartilages and enabling
visualization of the trachea
 tracheostomy tube is inserted
Surgical Cricothyroidotomy

52. 

53. 
53

54. 
 Laryngo-tracheal trauma
 fractures of the thyroid or cricoid cartilage or hyoid
bone
 Prolonged ventilation
 upper airway obstruction
54
Tracheostomy

55. 
 Thyroid cartilage, cricoid cartilage and tracheal rings
are palpated
 skin incision should be marked while the patient’s
head is in a normal position
 Vertical/horizontal skin incision
Procedure

56. 

57. 
 Assess breathing and ventilation
 Ventilation is compromised not only by airway
obstruction but also altered ventilatory mechanics or CNS
depression.
Breathing

58. 
 Direct trauma to the chest - # ribs - rapid, shallow
breathing and hypoxemia
 Intracranial injury - abnormal patterns
 spinal cord injury – paralysis of intercostal muscles
– unable to meet increased demand

59. 
 A: Airway obstruction
 T: Tension pneumothorax
 O: Open pneumothorax
 M: Massive hemothorax
 F: Flail chest
 C: Cardiac tamponade
Life-threatening Thoracic Injuries

60. 
 Air accumulation within the pleural space
 Collapse of affected lung
 Pushing of other contents of mediastinum to the opposite
side
 Compression of heart and major vessels and reduced venous
return
 positive-pressure ventilation worsens tension pneumothorax
 Maybe seen as complication of central line insertion in
polytrauma
Tension Pneumothorax

61. 
 chest pain
 air hunger
 respiratory distress
 tachycardia
 Hypotension
 tracheal deviation
 unilateral absence of breath sounds
 hyper resonant percussion note
Clinical Features

62. 
Collins J, Stern EJ. Chest Radiology: The Essentials. Lippincott Williams & Wilkins;
2012. 360 p.

63. 
 immediate decompression by insertion of a large-
bore needle into the second intercostal space
 Definitive treatment - insertion of a chest drain into
the fifth intercostal space
Treatment

64. 
 Identify the second intercostal
space in the midclavicular line on
the affected side
 Insert large bore catheter (12-14
gauge) over the top of rib into ICS
 Puncture the parietal pleura and
push 1 cc of air so as to remove
tissue tag at the end of catheter
 Remove the plunger of syringe
attached to catheter
 Sudden escape of air happens
Needle Thoracocentesis

65. 
 Identify the insertion site at the nipple level (fifth intercostal
space) anterior to the mid axillary line on the affected side.
 Make a 3-cm transverse incision and bluntly dissect through
the subcutaneous tissue just above rib.
 Puncture the parietal pleura
 perform a finger sweep with a gloved finger through the
incision, to avoid injury to other organs and to clear adhesions
and clots.
 Insert the tube and advance into the pleural space to the
desired length
Chest Drain Insertion

66. 

67. 
 rapid accumulation of more
than 1500 mL of blood in the
chest cavity.
 Damage to great vessels
 Dull percussion note
 Hypovolemia
 Drainage followed by
thoracotomy
Massive Hemothorax

68.  result of trauma associated with multiple rib fractures with
a number of ribs being fractured in two places
 chest wall loses bony continuity with the rest of the thoracic
cage
 disruption of the normal chest wall movement
Flail Chest

69.  injury to the underlying
lung parenchyma -
pulmonary contusion
 paradoxical breathing
 asymmetrical and
uncoordinated movement
of chest wall
 Crepitus
Flail Chest

70. 
 adequate ventilation
 Splinting the area with sandbag/ iv fluid bag
 administration of humidified oxygen
 fluid resuscitation
 Good analgesia
Treatment

71. 
 Penetrating/ blunt injury
 pericardium fills with blood from the heart, great
vessels
 interfere with cardiac filling
 Beck’s triad
 distended neck veins
 decline in arterial pressure
 muffled heart sounds
Cardiac Tamponade

72. 
 Kussmaul’s sign (a rise in venous pressure with
inspiration when breathing spontaneously)
 Aspiration of pericardial blood – pericardiocentesis
 Puncture the skin 1 to 2 cm inferior and to the left of
the xiphochondral junction, at a 45-degree angle to
the skin.
 Carefully advance the needle upward, aiming
toward the tip of the left scapula
 Once needle enters the blood-filled pericardial space,
withdraw as much blood as possible
Cardiac Tamponade

73. 
 Acute blood loss - 0% to 40% of trauma deaths
 Leads to Shock
HYPOVOLEMIC SHOCK
Clincal state of cardiovascular collapse
characterized by acute reduction of effective
circulating blood volume, inadequate perfusion of
cells & tissues.
Circulation And Hemorrhage Control

74. Shock is of 2 types
 Primary (initial)
 Secondary (true)
Primary –
transient attack resulting from sudden reduction of
venous return
 It occurs immediately following trauma, severe pain,
emotional over reaction
pale & clammy limbs, weak & rapid pulse& low BP
Secondary- due to hemodynamic derangements with
hypoperfusion of cells.
Shock

75.  SECONDARY (True Shock)
 Hematogenic/Hypovolaemic/Oligamic Shock
 Obstructive Shock / Traumatic Shock
 Neurogenic Shock
 Cardiogenic Shock
 Septic Shock
Shock

76. 
General Clinical Features Of Shock
 Hypotension (Systolic BP<70mmHg)
 Tachycardia (>100/min)
 Cold , Clammy Skin
 Rapid,Shallow Respiration
 Drowsiness,Confusion,Irritability
 Oliguria (Urine Output<30ml/hour)
 Multi-Organ Failure
Clinical Features

77. 
Stages In Shock
 Initial Shock
 Progressive Shock
 Irreversible Shock
Shock

78. 
 inadequate tissue perfusion and oxygenation and anaerobic
glycolysis results in lactic acid production
 coagulation factor and platelet dysfunction combined with
coagulation factor consumption a profound coagulopathy
 Triad of
 Metabolic acidosis
 Hypothermia
 coagulopathy
Shock

79. 
 stop hemorrhage
 minimize contamination
 restore near-normal physiology
Treatment Objectives

80. 

81. 
 Prevention of further blood loss and the earliest
restoration of tissue perfusion
 External hemorrhage is identified and controlled by direct
manual pressure
 Occult bleeding is thoracic and abdominal cavities, the
pelvis, the retroperitoneal space
 pneumatic antishock garment (PASG)
Initial Management of Hemorrhagic Shock

82. 

83. 
 Peripheral cannulae – large bore cannulae  rate of
flow proportional to 4th power of radius
 central line into the femoral or subclavian vein
 Crossmatch,full blood count; RFT,LFT and
electrolytes.
Management

84. 
 restore critical organ perfusion
 2 L of RL / 20 ml/kg RL
 3 type of responses
 Responder : vital signs return toward normal
Loss of less than 20% of circulating volume
and are not actively bleeding
Fluid Replacement

85. 
 Transient responder: The vital signs initially improve but
then deteriorate.
 still actively bleeding from an occult site.
 require transfusion with blood
 Identify source of bleeding
 Nonresponders: The vital signs do not improve.
 blood loss is continuing at a rate at least equal to the rate of
fluid replacement.
 Central line
 Immediate surgery and transfusion
Fluid Replacement

86. 
 Colloids are larger molecular weight, and hence expand
the intravascular compartment more effectively
 improve oxygen transport, myocardial contractility and
cardiac output
 More risk of anaphylactic complications
 Crystalloids are cheap and safe
 3-4 times greater volume is required
 Causes hypothermia and dilution of clotting factors
Crystalloid, colloid and blood

87. 
Corrects both water and electrolyte imbalance
 Water and salt depletion as in vomiting, diarrhoea
 Hypovolemic shock.
 CONTRA-INDICATIONS:
 Hypertensive patients
 Patientswith edema due to CCF
Isotonic saline

88. 
 Rapidly expands intravascular volume.
 The most physiological IV fluid.
 Sodium lactate metabolises to provide
bicarbonate
1. severe hypovolemia.
2. For replacing fluid in post-op patients
3. For diarrhoea induced hypovolemia.
4. Diabetic ketoacidosis.
88
RL

89. 
 CONTRA-INDICATIONS
1. In severe CHF.
2. Severemetabolic alkalosis.
89

90. 
Advantages
i. More effective in treating hypotension than crystalloids.
ii. Increase in plasma volume is for a prolonged period.
iii. Improve the hemodynamic status.
iv. Higher systemic oxygen delivery.
Disadvantages
i. Expensive.
ii. Anaphylactic reactions
Indications
i. To treat sudden hypotension due to major blood loss, till blood
is awaited , or to avoid blood transfusion.
Colloids

91. 
Type of fluid Effective plasma volume
expansion/100ml
duration
5% albumin 70 – 130 ml 16 hrs
25% albumin 400 – 500 ml 16 hrs
6% hetastarch 100 – 130 ml 24 hrs
10% pentastarch 150 ml 8 hrs
10% dextran 40 100 – 150 ml 6 hrs
6% dextran 70 80 ml 12 hrs
91

92. 
 Crystalloids – recommended as the initial fluid of choice in
resuscitating patients from hemorrhagic shock
Svensen C, Ponzer S… Volume kinetics of Ringer solution after
surgery for hip fracture. Canadian journal of anesthesia 1999 ; 46 : 133 -
141
 COCHRANE Collaboration in critically ill patients –
“ No evidence from RCT that resuscitation with colloids reduces the
risk of death, compared with crystalloids in patients with trauma or
burns after surgery”
Roberts I, Alderson P, Bunn F et al : Colloids versus crystalloids for
fluid resuscitation in critically ill patients.. Cochrane Database Syst
Rev(4) : CD 000567, 2004
92
Fluids

93. 
Blood Transfusion

94. 
 Hb concentrations below 6 g/dL
 no significant differences were found in 30-day
mortality rates between those in whom ‘restrictive’
transfusion therapy was used and those in whom the
transfusion therapy was applied ‘liberally’ (triggering
Hb values between 7-8 g/dL and around 10 g/dL,
respectively
94
When To Start Transfusion??
Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for
the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

95. 
Blood Transfusion

96. 
MABL = (Starting pt Hct – 25) X Estimated blood vol
Starting pt Hct
MABL= [EBV x (H initial- H final)]/H initial
H final = 30
Estimated blood volume – males 75 ml/kg
females 65 ml/kg
96Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for
the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

97. 
 Incompatible fluids Electrolyte and colloid solutions
containing any calcium (e.g. Haemaccel)
 5 % dextrose hemolyses RBCs
97Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for
the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

98. 
 1. Immediate
 acute haemolytic reactions
 febrile non-haemolytic reactions
 Anaphylaxis
 transfusion-related acute lung injury – TRALI
 2. Delayed
 delayed haemolytic reactions
 3. Immediate non-immunological
 bacterial contamination
 circulatory overload
 Air embolism/hypothermia
Adverse Reactions

99. 
 target mean arterial pressure (MAP) of 50 mm Hg
 decrease postoperative coagulopathy and lower the risk
of early postoperative death and reduce the amount of
blood product transfusions and overall IV fluid
administration.
Hypotensive Resuscitation

100. 
 Level of consciousness
– Best indicator of central perfusion & deterioration of patient
status
 Pupils
 GCS
 A: Alert
 V: responds to Vocal stimuli
 P: responds to Painful stimuli
 U: Unresponsive to all stimuli
Disability

101. 
Jennett and Teasdale in the
early 1974
revised in 1976- sixth point -
“withdrawal from painful
stimulus
13-15  mild head injury
8-12 moderate
<8  severe

102. 
Infants & children

103. 
Alert
Confused
Drowsy
Unresponsive
AVPU/ACDU

104.  Category A moderate to severe (definite) TBI:
1. Death caused by this TBI
2. LOC of 30 minutes or longer
3. Post-traumatic anterograde amnesia of 24 hours or
longer
4. Worst GCS full score in the first 24 hours less than 13
5. One or more of the following present: EDH, SDH,
Contusion
 Category B
1. Loss of consciousness of momentary to less than 30 minutes
2. Post-traumatic anterograde amnesia of momentary to less than
24 hours
3. Depressed, basilar or linear skull fracture
Mayo Head Injury Classification System For Traumatic Brain
Injury

105. 
 Category C
1.if one or more of the following symptoms are present:
2. blurred vision; confusion dizziness; focal neurologic
symptoms; headache; nausea

106. 
106
Revised Trauma Score (RTS)
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR
range 0 to 7.8408 RTS < 4 – severe injury
1981 by Champion et al.

107. 
107
Mainz score

108. 
 Complete exposure is a must  avoid hypothermia
 warm ambient room, overhead heating, and warmed
IV fluids
Exposure

109. 
 assessment of pulse and respiratory rates;
 systolic and diastolic blood pressures;
 pulse oximetry;
 Temperature
 ECG monitoring
 urinary catheter recording of urine output
 NG tube aspiration
Adjuncts To The Primary Survey

110.  complete and comprehensive head to- toe evaluation
 history and circumstances leading to the injury
 physical examination of the patient
 reassessment of all vital signs.
 Six potentially lethal injuries that should be evaluated
 Pulmonary contusion
 aortic disruption
 tracheobronchial disruption
 esophageal disruption
 traumatic diaphragmatic hernia
 myocardial contusion
Secondary Survey

111. 
 A: Allergies
 M: Medications currently used
 P: Past illnesses and Pregnancy
 L: Last meal
 E: Events and Environment related to the injury
History

112. 
Scalp
 Lacerations
 Contusions
 hematomas
 bone surface irregularities
Physical Examination

113. 
 pupillary response - shape, equality, and light reaction of
the pupils
 eye injury - blunt or penetrating
 Direct injury to the optic nerve
Eyes

114. 

115. 
 unstable cervical spine injury
– unless otherwise proven
 Cervical spine tenderness,
subcutaneous emphysema
 laryngeal fracture
 Lateral and AP views -seven
cervical vertebrae and the first
thoracic vertebra (C1- C7/T1
junction)
115
Neck and Cervical Spine

116. 
 Pain, dyspnea, and hypoxia
 pneumothorax and
 large flail segments
 Contusions and hematomas occult pulmonary or
cardiac injury
 Distended neck veins  cardiac tamponade or
tension pneumothorax
Chest

117. 
 Intra abdominal bleed should be suspected if there
are fractures of the ribs that overlie the liver and the
spleen
 Blunt/penetrating trauma
 Lap belts
 Focused assessment with sonography for trauma -
FAST
Abdomen

118. 
 contusions,hematomas, lacerations, and urethral
bleeding.
 Must before catheterization
Perineum, Rectum, and Vagina

119. 
 Contusions, lacerations, deformities
 Peripheral pulses
 Motor and sensory impairement
 Pelvic fractures are suggested by:
 ecchymosis over the iliac wings, pubis, vagina, or scrotum.
 pain on palpation.
 mobility of the pelvis in response to gentle anteroposterior
pressure in the unconscious patient
Musculoskeletal Assessment

120. 
 electrical shock–like pain radiating down the spine
or into the limbs nerve root compression
Spinal Cord Assessment

121. 

122. 
122

123. 
123

124. 
 With meticulous and rapid assessment and
management it is possible to add years to peoples life
Conclusion

125. 
 Oral & Maxillofacial Trauma – Fonseca 3rd volume – 4th
edition
 Maxillofacial trauma and esthetic facial reconstruction –
Peter Wardbooth, Eppley
 Maxillofacial injuries – N.L. Rowe and J.LI Williams
 Short hand book of surgery – Love and Bailey
References

126. 
126