Initial Management of the Trauma Patient

1. INITIAL MANAGEMENT OF
TRAUMA PATIENTS
DR. HADI MUNIB
ORAL AND MAXILLOFACIAL SURGERY RESIDENT

2. OUTLIN
E
• Assessment of the severity of the injury
• Glasgow Trauma Scale
• Primary Surveys: ABC
• Airway Maintenance
• Breathing
• Circulation
• Head and Neck area
• References

3. ASSESSMENT OF
SEVERITY
• Significant data exist to suggest that death from trauma has a trimodal
distribution:
• First Peak: Death within seconds; Brain injury
• Second Peak: Death within the first few hours of injury; Golden Hour
• Third Peak: Death after Days or weeks of injury; Sepsis or MOF
• Triage.

4. • Non-urgent injuries: 80% of all injuries
• Urgent injuries – Not life threatening: 10 – 15%
• Urgent injuries – Life Threatening: 5% of all injuries but 50% of
deaths by trauma.
ASSESSMENT OF
SEVERITY

5. • Vital Signs:
• BP
• HR
• RR
• Temperature
• Arterial oxygen tension (PaO2) [70 and 100 mm Hg.]
ASSESSMENT OF
SEVERITY

7. GLASGOW TRAUMA
SCALE

8. TRAUMA SCALE AND REVISED TRAUMA SCALE
• The extent of injury to vital systems to provide proper triage and
treatment of the patient.
• Trauma Score incorporated five variables: GCS, RR, Respiratory
expansion, SBP, and capillary refill.

10. PRIMARY SURVEYS
• Airway Maintenance and C-Spine
• Breathing
• Circulation
• Disability
• Exposure

11. AIRWAY MAINTENANCE AND C-
SPINE
• Highest Priority; Methods
• Chin-Lift
• Jaw Thrust
• Oro-Pharyngeal airway
• Naso-Pharyngeal airway
• Endo-tracheal intubation
• Tracheostomy
• Cricothyroidotomy

18. BREATHIN
G
• Look
• Listen
• Feel
• Exchange of air does not mean adequate ventilation

19. PNEUMOTHORA
X
• A defect in the chest wall, allowing the air to be moved in and out of
the pleural cavity with each respiration.
• Graded as Small 15- 60% or large > 60%
• Open or closed

20. OPEN
PNEUMOTHORAX
• Open wound
• Collapse on inspiration, Slight expansion on expiration
• Coverage of the defect with sterile occlusive dressing
• Chest tube.

21. CLOSED
PNEUMOTHORAX
• Blunt Trauma, Fractured Rib
• Hyper-Resonance and Absent breath sounds
• Upright Chest X-Ray
• Coverage with occlusive dressing and chest tube [Where to place
it?]
• Midclavicular line or Mid-Axillary
• 2nd intercostal space or 5th intercostal space

24. TENSION PNEUMOTHORAX
• One way valve
• Trachea and mediastinum are displaced, compression on inferior vena cava
• PEEP
• Life threatening
• Large bore needle (14-16 Gauge) 2nd intercostal space
• Chest Tube

25. TENSION
PNEUMOTHORAX
• Severe respiratory distress
• Hypotension
• Unilateral absence of breath sounds
• Hyper resonance to percussion over affected hemithorax
• Neck vein distention (can be absent in hypovolemic patients)
• Tracheal deviation (late finding—not necessary to confirm clinical diagnosis)
• Cyanosis (preterminal)
• Rapid onset can occur after intubation and positive pressure ventilation

27. HEMOTHORA
X
• Blood collection in pleural cavity due to a penetrating Trauma
• Hypovolemic Shock, Hypotension, a decreased cardiac output, and metabolic
acidosis.
• Treatment consists of
1. Restoration of the circulating blood volume with transfusion of fluids
through large-bore intravenous lines
2. Control of the airway and support of the ventilation
3. Drainage of the accumulated blood from the pleural cavity
• 5th intercostal space.

29. FLAIL
CHEST
• Multiple Rib fractures; Paradoxic Breathing  Visually obvious
• Relatively high Morbidity at 12 to 50%.
• Management:
1. Initial stabilization of the loose segment with an external splint. [atelectasis if used
for more than 30 minutes]
2. Intercostal nerve blocks to block the pain from the fractured ribs
3. A volume-cycled respirator with endotracheal intubation to provide PEEP
and intermittent mandatory ventilation.

31. CIRCULATIO
N
• Hemorrhage
• Minimum of Two large Bore needles IV catheters should be
inserted peripherally if fluid resuscitation is required
• Cross Matching

33. CARDIAC
TAMPONADE
• Blunt or penetrating trauma may cause blood to accumulate in the pericardial sac.
• Inadequate cardiac filling during diastole, diminished cardiac output, and
circulatory failure.
• The Beck’s triad of
1. Decreased systolic blood pressure levels
2. Distended neck veins – more distention during inspiration (Kussmaul’s sign).
3. Muffled heart sounds.

34. CONTROL OF
BLEEDING
• Direct Pressure
• Ice bags
• Sutures with no cosmetic considerations
• Liquid Thrombin or epinephrine
• Next step: IV Resuscitation fluids

35. IV RESUSCITATION FLUIDS
• Ringer’s Lactate
• 0.9% Normal Saline
• Volume Expanders: Colloids vs. Crystalloids
• Blood and Blood products if needed

37. NEUROLOGICAL
EXAMINATION
• Lack of consciousness with altered pupil reaction to light
requires an immediate CT scan of the head and management
with mannitol or fluid restrictions.

38. EXPOSURE OF THE
PATIENT
• The patient should be completely disrobed so that all of the body can be
visualized, palpated, and examined for injuries or bleeding sites.
• The clothing must be completely removed, even if the patient is secured
to a spinal backboard.
• Frequent careful reevaluation of the injured patient’s vital signs is
important to monitor the patient’s ability to maintain an adequate
airway, breathing, and circulation.

39. SECONDARY
ASSESSMENT
• X-Rays, MRI, CT scans of
• Head and Skull
• Chest
• Maxillofacial Area and Neck
• Spinal Cord
• Abdomen
• Genitourinary Tract
• Extremities

40. MAXILLOFACIAL AREA AND
NECK
• Maxillofacial injuries may cause airway compromise from blood and
secretions
• The physical examination should begin with an evaluation for soft tissue
injuries.
• The oral cavity should be inspected and evaluated for lost teeth
• The neck should be examined for injuries.

41. • 10-20% of Maxillofacial injuries are associated with
C-spine injuries.

42. REFERENCE
S
• Chapter 18: Initial Management of Trauma Patients

43. THANK YOU