it contains a protocol for managing trauma patients. division of patients according to triage. Primary and secondary management of these patients.

1. INITIALMANAGEMENT OF
TRAUMA PATIENTS
• By- Dr. Ashutosh Dod
2nd year Pg.
Dept. of OMFS

2. • CONTENT
1. Introduction
2. Primary survey
• Airway
• Breathing
• Circulation
• Disability
• Exposure of patient
3. Secondary Survey (AMPLE history)
4. Assessment through Scales
5. References

3. 3
• Trauma annually affects hundreds of
individuals and costs billions of
dollars in direct expenditures
.
• The accurate and systematic
assesment of injury is essentials to
established the extent of injury to
vital structures. It forms the basis of
ATLS protocols.
• Prior to 1600s, several method is
used to move the patients to
hospitals like TRAVIOS.

4. • In 15th century king ferdinand of
spain develop ambulancia to
provide rapid medical care to their
soldier.
• The 1st civilian manufactured
ambulance in the US, a specialized
medical transport vehicle, was built
in 1890.
• Nowadays helocopters, jets,
specially design ambulanced are
used.

5. • TRIMODAL DISTRUBUTION
1st peak death-
Due to laceration of brain, brainstem, upper spinal cord, heart,
aorta.
2nd peak death-
Due to CNS injury or hemorrhage.
Period after this injury is called ‘Golden Hour’
Because these patients may be saved with rapid assessment and
management of there injury.
3rd peak death-
Due to sepsis, multiple organ failure.

6. TIME AND TIDE WAITS FOR
NONE
6
 Severe -5% of all injuries, but represent more than 50% of all trauma
deaths
 Urgent- 10% to 15%
 Non urgent – 80 %, not constitute immediate threat to life.
Three categories

7. Assessmentprinciples–American College of
Surgeons
7
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. reevaluation
5. Definitive care

8. PREHOSPITALPHASE
8
 Pre-hospital medicine exist in 2 level,
Basic life support and advanced life support.
 The trauma ambulance and paramedics
 Convey the status and number of victims
to the hospital
 Provide on site care
 ventilation and cervical spine stabilization

9.  Pneumatic antishock 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.
9
Multiple casualties
 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.

10. TRIAGE
10
 A method of quickly identifying victims who
have immediately life- threatening injuries
AND who have the best chance of surviving
1. Red - Immediate (critical)
2. Yellow - Delayed (urgent)
3. Green - Minor (ambulatory)
4. White – those who do not require treatment
5. Black - Deceased

11. START system
11
 Simple Triage And Rapid Transport
 respiratory status, perfusion status, and mental
status
 "immediate," "delayed," or "minor" category

12. HOSPITAL PHASE
12

13. Primary Survey
13
 A - Airway (with C-spineprecautions)
 B – Breathing and ventilation
 C – Circulation and hemorrhage
control
 D – Disability + neurological status
 E – Exposure + environment
 F- Frequent reassessment

14. 1. AIRWAY MAINTENANCE WITH CERVICAL
SPINE CONTROL
14
 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.
 Hyperextension or hyperflexion of the
patient’s neck should be avoided
 Cervical collars or neck support
should be given.
 Neuronal deficit and paralysis
 SUSPECT
, PROTECT&
DETECT

15. Assessment of airway
15
 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)
 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

16. Listen
16
 abnormal sounds.
 Noisy breathing, Snoring, gurgling - partial
obstruction of the pharynx or larynx.
 Hoarseness laryngeal obstruction.
 abusive patient -hypoxic
Feel
 location of the trachea and determine whether it is in
the midline
 foreign objects (e.g.,fractured teeth, fillings, dentures)
should be removed.

17. Reasonsforairwayobstruction
17
• 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

18. Jaw thrust or chinliftprocedure
18
 jaw thrust
 knuckles of the index fingers are placed behind the angle of the
mandible with thumbs apply pressure on the cheek bones at the same
time  lifts and displaces the mandible forward.
 breathing spontaneously  high-flow oxygen via
the facemask
 not breathing a facemask with a bag- valve device
(AMBU bag) and is continuously bagged

19. Chin lift
 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
19

20. • 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.
20

21. Airway devices
21
1. oropharyngeal airway
 OPAshould 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

22. 2. Nasopharyngeal airway
 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.
22

23. 3. Laryngeal mask airway
 If orotracheal intubation has failed or bag-mask ventilation is not
maintaining sufficient oxygenation
 No cuff – chances of gastric distension and aspiration
23

24. 4. Multilumen esophageal airway
24
 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.

25. Injuriesto the larynxand trachea
25
 Neck swelling, dyspnea, voice alteration, or frothy hemorrhage
 Tenderness, and laryngeal or tracheal crepitus
 What should be done?
 Endotracheal intubation / surgical airway
DefinitiveAirway
 Defined as an inflated cuffed tube in the trachea.
 Oro tracheal.
 Naso tracheal
 Contra indicated - frontal sinus fractures, base of skull fractures, and ant
cranial fossa fractures
 surgical

26. Indications
Oral & Maxillofacial trauma – Fonseca Walker 39
Contraindications
 Ability to maintain a patent airway in a less invasive manner.

27. LEMON
27
FOR ENDO-TRACHEAL INTUBATION

28. Oral & Maxillofacial trauma – Fonseca Walker 42

30.  Rapid-sequence intubation with anesthetic agents,
neuromuscular blocking drugs, and esophageal occlusion by
cricoid pressure.
30
7 Ps
 Preparation
 Pre oxygenation
 Pre medication
 Paralysing
 Pressure (Cricoid)
 Placement
 Position
 Post intubation care

31. Premedication - LOAD
31
 L: Lidocaine
 O: Opioids (typically fentanyl)
 A: Atropine
 D: Defasciculating agent

32. STOPMAID
32
 S: Suction
 T
: Tools (e.g., blade, handle.)
 O: Oxygen
 P: Positioning
 M: Monitors (electrocardiogram [ECG], O2, CO2, blood pressure
[BP])
 A: Assessment, airway devices, assistant
 I: IV access
 D: Drugs
 Used as a reminder about the step and tools of intubations.

33. 33

34. 34

35. SurgicalAirway
35
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

37. 37

38. 38

39. Surgical Cricothyroidotomy
39

40. Surgical Cricothyroidotomy
40
 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

41. 41

42. Tracheostomy
42
Indication
 Laryngotracheal trauma
 Fractures of the thyroid or cricoid cartilage or
hyoid bone
 Prolonged ventilation
 Upper airway obstruction
Method :
 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

43. 43

45. BREATHING
45
 Assess breathing and ventilation
 Ventilation is compromised not only by airway obstruction but also
altered ventilatory mechanics or CNS depression.
 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

46. Life-threatening thoracicinjuries
46
 A: Airway obstruction
 T:Tension pneumothorax
 O: Open pneumothorax
 M: Massive hemothorax
 F: Flail chest
 C: Cardiac tamponade

47. 1. Tension Pneumothorax
47
 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

48.  positive-pressure ventilation worsens tension
pneumothorax
 Maybe seen as complication of central line insertion in
polytrauma
48
Clinical features
 Chest pain
 Air hunger
 Respiratory distress
 Tachycardia
 Hypotension
 Tracheal deviation
 Unilateral absence of breath sounds
 Hyper resonant percussion note

49.  Immediate decompression by insertion of a large-bore
needle into the second intercostal space.
 Definitive treatment - insertion of a chest drain or tube into
the fifth intercostal space.
49

50. Needle Thoracocentesis
50
 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

51. Chest Drain Insertion
51
 Identify the insertion site at the nipple level (fifth intercostal space)
anterior to the midaxillary 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

52. 52

53. Massive Hemothorax
53
 Rapid accumulation of more than 1500 mLof blood in the chest
cavity.
Causes :
 Damage to great vessels
 Dull percussion note
 Hypovolemia
 Drainage followed by thoracotomy

54. Flail Chest
54
 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
 injury to the underlying lung parenchyma - pulmonary contusion
 paradoxical breathing
 asymmetrical and uncoordinated movement of chest wall
 Crepitus

55. Treatment
55
 Adequate ventilation
 Splinting the area with sandbag/ iv fluid bag
 Administration of humidified oxygen
 Fluid resuscitation
 Good analgesia

56. Cardiac Tamponade
56
 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
 Kussmaul’s sign (a rise in venous pressure with inspiration
when breathing spontaneously)
 Aspiration of pericardial blood -
pericardiocentesis

57. Treatment :
 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
57

58. C: CIRCULATION AND HEMORRHAGE
CONTROL
58
 Estimated that hemorrhage accounts for 30% to
40% of mortality.
 Acute blood loss - 0% to 40% of trauma deaths
 Leads to Shock
 Clincal state of cardiovascular collapse
characterized by acute reduction of effective
circulating blood volume, inadequate perfusion of
cells & tissues.

59. Shock is of 2 types
59
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.

60.  PRIMARY (Initial Shock)
 SECONDARY (True Shock)
 HEMATOGENIC/HYPOVOLAEMIC/OLIGAMI C SHOCK
 OBSTRUCTIVE SHOCK / TRAUMATIC
SHOCK
 NEUROGENIC SHOCK
 CARDIOGENIC SHOCK
 SEPTIC SHOCK
60

61. 61
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
STAGES IN SHOCK 3 STAGES
Initial shock
Progressive shock
Irreversible shock

62.  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
62
Treatment
• Stop hemorrhage
• Minimize contamination
• Restore near-normal physiology

63. 63

64. Initial Management of
Hemorrhagic Shock
64
 Prevention of further blood loss and the earliest restoration of
tissue perfusion
 External hemorrhage is identified and controlled by
direct manual pressure
 Occult bleeding -thoracic and abdominal cavities, the pelvis, the
retroperitoneal space
 Pneumatic antishock garment (PASG)

65. Proper management
65
 Peripheral cannulae – large bore cannulae  rate of flow
proportional to 4th power ofradius
 venous cut-down, made 2 cm anterior and superior to the
medial malleolus into the greater saphenous vein
 central line into the femoral or subclavian
vein
 Crossmatch,full blood count; RFT,LFT and electrolytes;
ABG

66. Fluid Replacement
66
 Restore critical organ perfusion
 2 L of RL / 20 ml/kgRL
 3 type of responses
 Responder: vital signs return toward normal
 Loss of less than 20% of circulating volume and are not
actively bleeding

67.  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
67

68. Crystalloid, colloid and blood
68
 Colloids - larger molecular weight, and hence expand the
intravascular compartment more effectively – 1:1 ratio
 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

69. Isotonic saline
69
• Correct both water and electrolyte imbalance.
• Water and salt depletion in vomiting and diarrohea
• Contraindication
• Hypertensive patients.
• Patients with edema due to CHF.
RL
 Rapidly expand intravascular vol.
 It contain all minerals as in plasma of
human.
 Called as heartmen’s sol.
indication
 Severe hypovolemia
 Diabetic ketoacidosis
 Replacing fluid in postop. Pt.

70. 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 70

71.  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
71

72. Blood transfusion
72

73. 103
 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
Liumbruno G, Bennardello F,Lattanzio A, Piccoli P
,Rossetti G. Recommendations
the transfusion of red blood cells. Blood Transfus. 2009 Jan;7(1):49–64.

74. Adverse reactions
74
 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

75. Hypotensive resuscitation
75
 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.

76. D: DISABILITY
76
 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

77. 13-15  mild head injury
8-12 moderate
<8  severe
77
Jennett and Teasdale in the early 1974
revised in 1976- sixth point -
“withdrawal from painful stimulus

78. Infants & children
78

79. AVPU/ACDU
79
Alert
Confused
Drowsy
Unresponsive

80. MAYO HEAD INJURY CLASSIFICATION SYSTEM FOR
TRAUMATIC BRAIN INJURY
80
 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

81. 81

82. Injury Severity Score
82
Abbreviated injury score

83. RevisedTrauma Score(RTS)
116
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR
range 0 to 7.8408 RTS < 4 – severe injury
1981 by Champion et al.

84. Mainz score
117

85. EXPOSURE
85
 Complete exposure is a must  avoid
hypothermia
 warm ambient room, overhead heating, and
warmed IV fluids

86. ADJUNCTS TO THE PRIMARY
SURVEY
86
 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

87. SECONDARY SURVEY
87
 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

88. HISTORY
88
 A:Allergies
 M: Medications currently used
 P: Past illnesses and Pregnancy
 L: Last meal
 E: Events and Environment related to the injury

89. Physical examination
89
• Scalp
 Lacerations
 Contusions
 hematomas
 bone surface irregularities
• Eyes
 pupillary response - shape, equality, and light reaction of the
pupils
 eye injury - blunt or penetrating
 Direct injury to the optic nerve

90. 90

91. Neck and Cervical Spine
 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)
126

92. Chest
92
 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
Abdomen
 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

93. Musculoskeletal Assessment
93
 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

94. Spinal Cord Assessment
94
 Electrical shock–like pain radiating down the
spine or into the limbs nerve root compression

95. 95

96. Conclusion
96
 With rapid and meticulous assessment
management it is possible to add years to
peoples life

97. References
97
 Oral & Maxillofacial Trauma – Fonseca
Walker – 4th edition
 Maxillofacial trauma and esthetic facial
reconstruction – Wardbooth, Eppley
 Principles of OMFS- Petersons 3rd ed.

98. 136