THIS PRESENTATION WAS MADE AT IMA HOUSE IN BHUBANESWAR,ODISHA, BY DR.NIBEDITA PANI,HOD ,DEPT. OF ANAESTHESIOLOGY AND DR.PRERNA BISWAL,PG,ANAESTHESIOLOGY,SCBMCH,CUTTACK,

1. INITIAL ASSESSMENT OF
TRAUMA PATIENTS
•PROF.DR.NIBEDITA PANI
HOD,DEPT. OF ANAESTHESIOLOGY
& CRITICAL CARE,SCBMCH,CUTTACK
•DR.PRERNA BISWAL,SCBMCH.

2. TRAUMA
THE NEGLECTED DISEASE
OF MODERN DEVELOPING
NATIONS!!!

4. One day it could be anyone of
us!someone from our
family;some loved one!!!
Then what???
Everyday we come across a story about
someone’s loved one dying on the road and just
ignore it focussing on our day to day life!!!

5. EPIDEMIOLOGY
 3242 persons die each day around the world
 50 million people are disabled or injured each year.
 India : 1%of motor vehicles in the world but bears the
burden of 6% of global vehicular accidents.
 Unfortunately, a majority of trauma survivors are either
confined to bed or wheel chair for the rest of their lives

6.  The tragedy of India :
78% of the victims – men, 20 to 44 years,
causing significant impact on productivity.
 A vehicular accident reported every 3 min and
a death every 6 min on Indian roads

7. PITIABLE CONDITION OF INDIAN ROADS

8. PITIABLE ATTITUDE OF OUR
PEOPLE

9. Trimodal distribution of
death

11. GOLDEN HOUR
 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 in ED,
continued care in ICU have a definite and
significant role in preventing deaths due to
trauma.

12. PLATINUM MINUTES
 THE IMPORTANCE OF TIME IN TRAUMA IS
INCREASING AS EVIDENT FROM THE
EVOLUTION OF THE CONCEPT OF
“THE PLATINUM TEN MINUTES”

13. INDIAN SCENARIO
 No proper pre-hospital care
 No trained emergency physicians
 No trained nursing/paramedical staff
 No coordination between different specialties
MOST OF THE TRAUMA REALTED
DEATHS ARE PREVENTABLE AND ITS
HIGH TIME TO REALISE THIS FACT!!!

14. National Crime Records Bureau, Ministry Of Home Affairs
 A total of 3,94,982 accidental deaths were reported
in the country during 2012
 17 States/UTs have constituted high risk areas
reporting higher rates of ‘accidental deaths’ than the
all-India average of 32.6 deaths per one lakh of
population.
 Odisha has higher rate of ‘accidental deaths’ than
the all-India average i.e. 33.1.
ODISHAACCIDENTAL DEATHS
IN COMPARISION TO NATIONAL DATA

16. INITIAL APPROACH TO
TRAUMA CARE
 Process that consists of
-Initial primary assessment
-Rapid resuscitation
-A more thorough secondary
assessment
-Followed by diagnostic tests and
disposition.

17. OVERALL APPROACH
Anticipate the worst
Never make any assumptions
History and Exam have to make
sense
Don’t take short cuts
Document frequently
TEAMWORK

18. Don’t get distracted with “ugly injuries”

19. OBJECTIVES
• SYSTEMIC APPROACH TO
POLYTRMA
• APPLY PRICIPLES OF PRIMARY,
SECONDARY AND TERTIARY
SURVEY
• CORRECTLYASSESS PRIORITIES IN
MANAGEMENT OF POLYTRAUMA

20. TRAUMA TEAM
RADIOGRAPHER
AIRWAY DOCTOR
AIRWAY NURSE
CIRCULATION DOCTOR
CIRCULATION NURSE
ORTHO REGISTRAR
WARDSPERSON
SCRIBE NURSETEAM LEADERSOCIAL WORKER

21. • ANATOMICAL
• PHYSIOLOGICAL
• MECHANISM
TRAUMA TEAM
ACTIVATION CRITERIA

22. TRAUMA TEAM
ACTIVATION CRITERIA
ANATOMICAL
 INJURY TO 2/ MORE BODY REGIONS
 FRACTURE 2/ MORE LONG BONES
 SPINAL CORD INJURY
 AMPUTATION OF LIMB
 PENETRATING INJURY TO HEAD, NECK TORSO/
PROX. LIMB
 BURNS> 15% IN ADULTS, >10% IN CHILDREN,
AIRWAY BURNS
 AIRWAY OBSTRUCTION

23. TRAUMA TEAM
ACTIVATION CRITERIA
PHYSIOLOGICAL
 SBP<90mm Hg/ PR- >130BPM
 RR<10/ >30 PER MIN
 DEPRESSED CONSCIOUSNESS
 AGE>70YR WITH CHEST INJURY
 PREGNANCY>24 WEEKS WITH TORSO
INJURY

24. MECHANISM
 BIKER/ PEDESTRIAN HIT BY
VEHICLE>30KM/HR
 FALL>5 METRE
 FATALITY IN SAME VEHICLE
 MOTOR VEHICLE CRASH WITH
EJECTION
TRAUMA TEAM
ACTIVATION CRITERIA

25. TEAM LEADER CHECKLIST
 Trauma team activation prior to arrival
 Name tags worn
 Universal precaution in place
 Lead gowns in place
 X-ray cassette in place
 Warmed i.v fluids hanging
 O-neg blood ready, blood warmer and rapid infuser ready
 Trauma surgeon notified if SBP<90mm Hg
 Theatre notified
 Radiology notified

26. PRICIPLES OF INITIAL ASSESSMENT
RAPID PRIMARY
SURVEY
SIMULTANEOUS
MANAGEMENT OF
LIFE THREATNING
INJURIES

27. PRICIPLES OF INITIAL ASSESSMENT
APPLY
APPROPRIATE
MONITORING
DEVICES

28. PRICIPLES OF INITIAL ASSESSMENT
OBTAIN HISTORY
A-M-P-L-E
&
TETANUS STATUS
AMPLE
ALLERGY
MEDICATION
PAST HISTORY
LAST FOOD
EVENTS

29. PRICIPLES OF INITIAL ASSESSMENT
PERFORM DETAILED
SECONDARY
SURVEY(HEAD TO TOE)

30. PRICIPLES OF INITIAL ASSESSMENT
TRANSFER FOR
DEFINITIVE CARE

31. PRICIPLES OF INITIAL ASSESSMENT
APPLY
APPROPRIATE
MONITORING
DEVICES
OBTAIN HISTORY
A-M-P-L-E
&
TETANUS STATUS
RAPID PRIMARY
SURVEY
SIMULTANEOUS
MANAGEMENT OF
LIFE THREATNING
INJURIES
PERFORM DETAILED
SECONDARY
SURVEY(HEAD TO TOE)
TRANSFER FOR
DEFINITIVE CARE

32. THE PATIENT ARRIVES

33. PRE-HOSPITAL INFORMATION AND
HANDOVER
M-I-S-T
 MECHANISM OF INJURY
 INJURIES SUSTAINED OR SUSPECTED
 SIGNS- VITALS ON SCENE AND
DURING TRANSPORT
 TREATMENT INITIATED

34. PRIMARY SURVEY
 Identify the life-threatening conditions and
manage simultaneously
–A: Airway maintenance with cervical
spine protection
–B: Breathing and ventilation
–C: Circulation with hemorrhage
control
–D: Disability ( Neurologic status )
–E: Exposure ( Undress the patient &

35. SPECIAL GROUPS
PEDIATRIC
 Same Priorities and Approach
 Need for different amounts of
fluids and medications
 Need for equipment of varying
sizes
PREGNANT WOMEN
 Same Priorities and approach
 Anatomic and physiologic changes
 Potential two patients not one
 “TREAT THE MOTHER TO
TREAT THE FETUS”

36. ELDERLY
 Diminished physiologic
reserve
 Comorbidities
– Heart disease, Diabetes, lung
disease
 Multiple medication use
 Increased risk of death for any
given injury compared to
younger patient

37. AIRWAY ASSESSMENT
AND C-SPINE CONTROL
 THE NEW A-B-C
A Airway
B Be Careful of the Airway
C Concentrate on the Airway

38. AIRWAY ASSESSMENT AND C-SPINE
CONTROL
PATIENT CONSCIOUS
ORIENTED
FAILS TO RESPOND
APPROPRIATELY(DROW
SY OR UNCONSCIOUS)
ASK TO COUGH
C/I- EYE INJ., PULM. BAROTRAUMA,
TBI, SPINAL INJ
ASK TO TAKE DEEP BREATHS
ASSESS UPPER AIRWAY, CHEST EXPANSION
YES (VOCALISES
NORMALLY)
THREATENED AIRWAY
MANDATORY
INTUBATION
1. GCS<9
2. SEVERE FACIAL
INJURY OR BLEED
3. SEVERE FACIAL OR
NECK BURNS
CONSIDER INTUBATION
1. COMBATIVE PATIENTS
2. GCS -9-12
3. FACIAL OR NECK INJURY WITH
IMPENDING AIRWAY
COMPROMISE(PENETRATING INJURY)
NAD
SUPPLEMENTAL O2
CERVICAL COLLAR

39. MILS- MANUAL IN LINE
STABILISATION
ASSUME C-SPINE INJURY UNLESS PROVEN OTHERWISE .

40. OBSTRUCTED AIRWAY
 PRE-INTUBATION-
– SUPPLEMENT OXYGEN
– OROPHARYNGEAL SUCTION
– JAW THRUST
– ORO-PHARYNGEAL AIRWAY
 RAPID SEQUENCE INDUCTION AND ENDO-TRACHEAL INTUBATION
 DIFFICULT AIRWAY ANTICIPATED-
– AIRWAY INJURY
– HEAD AND NECK INJURY
– SHORT NECK
– REDUCED MOUTH OPENING
– UNDERSLUNG JAW
 SURGICAL AIRWAY
– CAN’T INTUBATE
– DISTORTED ANATOMY
 IN FAILED INTUBATION – LMA AS BRIDGE

41.  ADVANCED AIRWAY TECNIQUES-
– FOB
– specialised laryngoscopes
– Bougies
– double lumen tubes
 Laryngeal injury-immediate tracheostomy
 Atleast 3 assistants required FOR INTUBATION-
 MILS
 cricoid pressure
 DRUGS

42. BREATHING AND VENTILATION
 Do not confuse airway problem for ventilation problem
 Patent airway does not equal adequate ventilation.
 Need good gas exchange
– Oxygen in
– CO2 out
Rapid assessment of
 RR
 SPO2
 TRACHEA
 CHEST EXPANSION
 PERCUSSION
 AUSCULTATION

43. BREATHING WITH SUPPLEMENTAL
OXYGEN
 INSPECT:Equal chest rise,paradoxical chest
movements,contusion,sucking chest
wound,distended neck veins
 AUSCULTATE: equal breath sounds,absence of
breath sounds
 PALPATE:Trachea,chest wall
tenderness,subcutaneous emphysema,sternal and rib
fracture
 PERCUSS:dullness,hyperresonance
 If you think about giving oxygen, GIVE
IT!!!!!

44. TENSION PNEUMOTHORAX
 RESPIRATORY DISTRESS
 HYPERINFLATED CHEST
 DEVIATED TRACHEA
 DECREASED MOVEMENT
 DECREASED BREATHSOUND
 TACHYCARDIA
 HYPOTENSIONNEEDLE THORACOSTOMY VIA 2ND ICS IN MCL
FOLLOWED BY DEFINITIVE CHEST TUBE (4TH-
5TH ICS JUST ANTERIOR TO MAL CONNECTED
TO WATER UNDER SEAL DRAIN)

45. MASSIVE HEMOTHORAX
 SIGNS SIMILAR TO TENSION
PNEUMOTHORAX EXCEPT DULLNESS ON
PERCUSSION
 SHOCK
 T/T- TUBE THORACOSTOMY
– THORACOTOMY IN
 >1500ml DRAIN IMMEDIATELY
 >200ml/hr FOR 4 HOURS
– CONTACT CTVS EARLY.

46. OPEN PNEUMOTHORAX
 CHEST TUBE AT SITE
SEPARATE TO DEFECT
 COVER WOUND WITH 3
SIDES GAUZE
 DEFINITIVE
DEBRIDEMENT IN OT

47. FLAIL CHEST
 >2 RIB FRACTURES
IN 2 OR MORE PLACES
 PARADOXICAL
CHESTWALL
MOVEMENT
 ADEQUATE
VENTILATION
 REEXPAND LUNGS:
INTUBATION, IPPV,
CTVS CONSULTATION

48. PERICARDIAL TAMPONADE
 PENETRATING INJURY
 BECKS TRIAD
 ECHO/ FAST
 EMERGENCY ROOM THORACOTOMY/
URGENT THORACOTOMY
 ER THORACOTOMY IS
CONTRAINDICATED IN MOST CARDIAC
ARRESTS TO BLUNT TRAUMA
HYPOTENSION
DISTENDED
NECK VEINS
MUFFLED
HEART
SOUND

49. CIRCULATION AND HEMORRHAGE
CONTROL ASSESS-
– PULSE RATE AND CHARACTER
– SKIN COLOUR AND TEMPERATURE
– CONSCIOUS LEVEL(GCS)
– CAPILLARY REFILL TIME
– DECREASED URINE OUTPUT
– HYPOTENSION-A LATE SIGN WHEN≥ 30% BLOOD VOLUME
LOST.
 Stopping the bleeding:most important priority

50. IDENTIFY
 External hemorrhage
– Apply direct pressure
– No tourniquets except for traumatic amputations
 Be aware of possible sources of internal
bleeding both from blunt and penetrating
trauma
– Chest
– Abdomen
– Pelvic Fractures
– Long Bone Fractures

52. Primary Survey - Circulation
Table 251-4 Estimated Fluid and Blood Losses Based on Patient's Initial
Presentation
Class I Class
II
Class
III
Class
IV
Blood loss (mL)* Up to 750 750–1500 1500–2000 >2000
Blood loss (percent blood
volume)
Up to 15 15–30 30–40 40
Pulse rate <100 100–120 120–140 >140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure (mm Hg) Normal or
increased
Decreased Decreased Decreased
*Assumes a 70-kg patient with a preinjury circulating blood volume of 5 L.

53. MANAGEMENT OF
CIRCULATION
 Control bleeding with direct pressure
 Splint limb fractures
 Insert 2 large bore IV cannulas in adults or cut
down on long saphenous v
 Send off blood-cross match,coagulation
screen,Hb, hct,biochemistry,blood alcohol
level if req
 Intraosseous needle in children upto 10 yrs

54. Fluid replacement:adults upto 2-3 lt
crystalloid/colloid,
Children 20 ml/kg
Blood replacement
O neg,group specific or fully cross
matched packed cells
Remember other blood product
requirements: ffp, cryoppt, platelets

55. PITFALLS IN CIRCULATION
 Elderly - limited ability to increase HR
– BP often has little correlation to Cardiac output
 Children - abundant reserve, appear stable
then crash
 Medication use (Beta Blockers)
 Have an attitude of skepticism regarding a
patient’s “normal” blood pressure.

56. DISABILITY AND NEUROLOGIC
STATUS
Disability assessed by AVPU scale
 A. Alert i.e.obeys commands
 V. vocalises-inappropriate or incomprehensible
 P. Responsds to pain
 U. Unresponsive
NEUROLOGIC ASSESSMENT-GCS SCALE,pupil
reaction to light,limb movement
– Consider possible injuries-depressed skull fractures,
EDH, SDH, SAH, DAI, spinal injury
– Clearing the cervical spine-no spinal tenderness,normal
conscious state,normal neurlogical examination,no
major distracting injury,..collar may be removed and no
further investigation required

57. GLASGOW COMA SCALE
Variables Score
Eye opening Spontaneous
To speech
To pain
None
4
3
2
1
Verbal response Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Best motor response Obeys commands
Localizes pain
Normal flexion
Abnormal flexion
Extension
None
6
5
4
3
2
1

58. EXPOSE
You can’t treat what you don’t
find!
If you don’t look, you won’t see!

59. EXPOSURE

60. RESUSCITATION
 Protect/Secure airway & protect C-spine
 Breathing/Ventilation/Oxygenation
 Vigorous shock therapy
– At last two large - caliber IV line
– Crystalloid solution ( Ringer’s lactate 2~3 litter)
– Type-specific blood
– surgical intervention
 Protect from Hypothermia : 39oC warm IV fluid
 Urinary/gastric catheters unless contraindication

61. PRIMARY SURVEY ADJUNCTS:-
MONITOR
 VITALS
 ECG
 FOLEY’S CATHETER
 GASTRIC TUBE
 ABG
 PULSE OXIMETER
 URINE OUTPUT

62. PRIMARY SURVEY ADJUNCTS:- MONITOR
APPLY
APPROPRIATE
MONITORING
DEVICES

63. FOLEY’S CATHETER
 CONTRAINDICATED IN URETHRAL
INJURY
 SUSPECT URETHRAL NJURY
– INABILITY TO VOID
– UNSTABLE PELVIC FRACTURE
– BLOOD AT MEATUS
– SCROTAL HEMATOMA
– PERINEAL ECCHYMOSIS
– HIGH RIDING PROSTATE

64. GASTRIC TUBE
 RELIEVE GASTRIC DILATATION
 DECOMPRESS STOMACH BEFORE DPL
 REDUCE RISK OF ASPIRATION
 N.G TUBE – C.I. IN BASILAR SKULL #

65. PRIMARY SURVEY ADJUNCTS:-
DIAGNOSIS
 CXR
 PELVIS AP
 LATERAL C-SPINE
 DPL
 FAST

67. A PATIENT BROUGHT TO E.D. WITH
M- CAR DRIVER HIT TREE ON ROAD
SIDE(UNDER INFLUENCE OF
ALCOHOL)
I- HEAD AND CHEST
S- PR- 100/MIN; BP-90/60mm Hg; RR- 30/
min
T- 20 Gz i.v. line- 2 pints NS; O2 inhalation
Case Study

68.  ON PRIMARY SURVEY
– AIRWAY- CLEAR
– GCS- 7/15
– BREATHING-RR- 30/min, DECRASED BREATH
SOUNDS ON LEFT LUNG FIELD, HYPER-
RESONANT
– SpO2- 84%
– CXR- LEFT PNEUMOTHORAX
INTUBATE WITH MILS
ICTD- 5TH ICS
CIRCULATION-MEANWHILE BP IS 84/62mm Hg
DESPITE 1.5 L FLUID
NO VISIBLE SOURCE OF BLOOD LOSS
P/A RIGIDITY MORE IN RUQ, ABDOMINAL
DISTENSION, B.S.- PRESENT.

69.  X-RAY PELVIS- NAD
 FAST- COLLECTION IN ALL QUADRANTS
 OT NOTIFIED FOR URGENT
LAPAROTOMY
 DISABILITY- GCS- 7/15, PUPIL- B/L NSERL
 EXPOSURE PRIOR TO OT- RULE-OUT
HIDDEN INJURIES
 DAMAGE CONTROL LAPAROTOMY
 PATIENT SHIFTED TO ICU FOR
OBSERVATION AND FURTHER
MANAGEMENT.

70. BEFORE SECONDARY SURVEY
 Complete primary survey
 Establish resuscitation
 Normalization of vital functions

71. SECONDARY SURVEY
The complete
history and
physical
examination

72. SECONDARY SURVEY
History
Physical exam: head to toe
“Tubes OR fingers in every orifice”
Complete neurological exam
Special diagnosis tests
Re-evaluation

73. Secondary survey
History
“AMPLE”
A:Allergies
M:Medication currently being taken by the patient
P:Past illness and operations,pregnancy
L:Last meal
E:Event/Environment related to the injury

74. Secondary survey
HEAD
 Signs of skull base
fracture
 Pupillary size
 Hemorrhages of
conjunctiva/fundi
 Visual acuity
 Penetrating injury
 Contact lens
 Dislocation of lens
 Hyphaema
 Ocular movement
 Posterior scalp
laceration

75. Secondary survey
MAXILLOFACIAL
 Associated with airway obstruction or major
bleeding
 Fracture cribriform plate
 No NG tube [performed oral route]

76. Secondary survey
NECK
 Cervical tenderness, subcutaneous
emphysema
 Oesophageal injury
 Tracheal/laryngeal injury
 Carotid injury (penetrating/blunt)

77. Secondary survey
CHEST
 Inspect
 Palpate
 Percuss
 Auscultate
 Obtain x-rays

78. Secondary survey
ABDOMEN
 Inspect
 Auscultate
 Palpate
 Percuss
 Reevaluate
 Special studies

79. Secondary survey
 Perineum:contusion,hematoma, laceration,urethral
blood
 Rectum:sphincter tone,high riding prostate,pelvic
fracture,rectal wall integrity,blood
 Vagina:blood,laceration

80. Secondary survey
Musculoskeletal
 Contusion, deformity
 Pain
 Perfusion
 Peripheral
neurovascular status
 X-ray

81. Secondary survey
Neurologic: brain
GCS Score
Lateralizing signs
Frequent reevaluation
Prevent secondary brain
injury
Neurologic: spine and cord
Complete motor and
sensory exams
Imaging as indicated
Reflexes

82. ADJUNCTS TO SECONDARY
SURVEY
Special diagnostic tests as indicate
 CT
 Contrast x-ray studies
 Extremity x-ray
 Endoscopy
 Ultrasound

83. DEFINITIVE CARE
 OR
 ICU
 Refer

84. DAMAGE CONTROL
 Multi trauma pt. triad of
coagulopathy,hypothermia,met
abolic acidosis-interfernce with
surgical mgt
 Goal- 1.control hmg
2. prevent contamination
3. protect pt. from further
injury
 Proceed to definitive surgery
once pt stabilises
 Clear communication between
surgeon,anesthesiologist and
intensivist

85. TERTIARY SURVEY
 Completed within 24 hours and documented
on designated forms
 Review of diagnostic tests and examination
of pt to ensure all injuries have been
idntified

86. PAIN CONTROL
 Relief of pain is an important part of the
management of the trauma patient
 Titrate IV opiates and anxiolytics
 Be aware that these agents can hypotension
and respiratory depression

88. A GOOD BEGINNING ALMOST
ASSURES SUCCESS!!!
EMERGENCIES DON’T GIVE US
A SECOND CHANCE…..

91. Medicine is not the exact science,
I shall use my experience, knowledge
and judgement to its best,
I may go wrong or anything with
patient may go wrong anytime

92. I guarantee nothing but my honest
effort and care for you,
I am not God, but well-trained
professional wanting to take care of
patients