Trauma management involves initial assessment and stabilization of airway, breathing, circulation, disability and exposure (ABCDE). The primary survey assesses life threats and guides resuscitation efforts. Key priorities include spinal immobilization, hemorrhage control, and treating tension pneumothorax. Secondary survey involves full head-to-toe examination and history to identify all injuries requiring attention or monitoring. Management requires a multidisciplinary team approach. Proper preparation and coordination of care is essential for optimal trauma outcomes.

1. MANAGEMENT
OF TRAUMA
GOLDLIN BEAULAH.A
CLINICAL INSTRUCTOR -ED

2. TODAYS DISCUSSION…….
• Definition of trauma
• Trimodal distribution of trauma death
• Mechanism of injury
• Initial assessment and management of trauma

3. ARE YOU AWARE?
• Every day 16,000 people die from trauma
• Trauma accounts for 16% of global burden of disease.
• It also accounts for 2.7 million hospital admissions per year
in US
• WHO predicts by 2020, RTA will be second leading cause of
death

4. ARE YOU AWARE? • 5.8 MILLION
DEATHS PER
YEAR
• 3.2% MORE
DEATHS THAN
HIV ,TB ,
MALARIA
COMBINED

5. WHAT IS TRAUMA?????
• THE TERM DERIVED FROM THE GREEK FOR WOUND
• IT REFERS TO ANY BODILY INJURY
• IT DEFINED AS TISSUE INJURY DUE TO DIRECT EFFECTS
OF EXTERNALLY APPLIED ENERGY,ENERGY MAY BE
MECHANICAL,THERMAL,ELECTRICAL,ELECTROMAGNETIC
OR NUCLEAR
• INCLUDED:BURNS,DROWNING,SMOKE INHALATION,SLIP &
FALL.
• EXCLUDED:POISONING/TOXIC INGESTION

6. TRIMODAL DISTRIBUTION OF TRAUMA
DEATH
• FIRST PEAK :SECONDS-MINUTES
 HEART,BRAIN,LARGE VESSEL &SPINAL CORD
INJURY
 BEST TREATED BY PREVENTION
• SECOND PEAK:MINUTES-HOURS
 EPI/SUB DURAL HEMATOMA,HEMO/PNEUMO
THORAX,SPLEEN/LIVER INJURY
 BEST TREATED BY APPLYING PRINCIPLES OF ATLS
• THIRD PEAK:DAYS-WEEKS
 SEPSIS,MSOF
 DIRECTLY CORRELATED TO EARLIER TREATMENT

8. MECHANISM OF INJURY
• BLUNT TRAUMA
INJURIES IN WICH TISSUES ARE NOT PENETRATED BY
EXTERNAL OBJECT

9. • FALLS FROM HEIGHT
 SEVERITY OF INJURIES IMPACTED BY
o HEIGHT
o POSITION
o SURFACE
o PHYSICAL CONDITION

10. • PENETRATING TRAUMA
 INVOLVES DISRUPTION OF SKIN AND TISSUES IN A
FOCUSED AREA

11. • GUNSHOT WOUNDS
• SEVERITY DEPENDS ON
 DISTANCE OF VICTIME
 TYPES OF TISSUE STRUCK

12. • MOTOR VEHICLE CRASHES

13. • IMPACT PATTERNS
 FRONTAL OR HEAD ON IMPACTS

14.  LATERAL OR SIDE IMPACTS

15.  ROLLOVERS

16. • PEDESTRIAN INJURIES

17. WHAT CAN BE DONE ABOUT THESE
DEATHS?
• MOST OF THE TRAUMA RELATED DEATHS ARE
PREVENTABLE AND ITS HIGH TIME TO REALISE THIS
FACT

18. INITIAL ASSESSMENT AND
MANAGEMENT

19. • 1. Preparation
• 2. Triage
• 3. Primary Survey (ABCDEs)
• 4. Resuscitation
• 5. Adjuncts to primary survey & resuscitation
• 6. Secondary Survey (head to toe evaluation & history)
• 7. Adjuncts to secondary survey
• 8. Continued post-resuscitation monitoring & re-evaluation
• 9. Definite care.

20. 1.PREPARATION
• Pre hospital phase
• Notify receiving hospital
• Send to the closest, appropriate facility
• In hospital phase
• Team assembly
• Equipment's made readily available
• Ancillary departments informed
• Hospital personal protection

21. PRE HOSPITAL INFORMATION &HAND
OVER
• M-I-S-T
• MECHANISM OF INJURY
• INJURIES SUSTAINED OR SUSPECTED
• SIGNS- VITALS ON SCENE AND DURING TRANSPORT
• TREATMENT INITIATED

22. PREPARATION FOR PATIENT ARRIVAL
AIRWAY
DOCTOR
CIRCULATION
NURSE
AIRWAY
NURSE
CIRCULATION
DOCTOR
ORTHO
REGISTRAR
SOCIAL
WORKER
TEAM
LEADER
SCRIBE
NURSE
RADIOGRAPHER

23. TEAM LEADER CHECKLIST
• TRAUMA TEAM ACTIVATION PRIOR TO
ARRIVAL
• UNIVERSAL PRECAUTION IN PLACE
• LEAD GOWNS IN PLACE
• WARMED IV FLUID HANGING
• O-VE BLOOD READY,BLOOD WARMER
&RAPID INFUSER READY
• OR NOTIFIED
• RADIOLOGY NOTIFIED

24. PRINCIPLES OF INITIAL ASSESSMENT
APPLY
APPROPRIATE
MONITORING
DEVICES
OBTAIN HISTORY
A-M-P-L-E
&TETANUS
STATUS
RAPID PRIMARY
SURVEY
SIMULTANEOUS
MANAGEMENT OF LIFE
THREATENING INJURIES
AMPLE
ALLERGY
MEDICATION
PAST HISTORY
LAST FOOD
EVENTS
PERFORM
DETAILED
SECONDARY
SURVEY(HEAD
-TOE)
TRANSFER FOR
DEFINITIVE CARE

25. 2.TRIAGE
• Sort patients by level of acuity (CTAS)

26. 3.PRIMARY SURVEY
• Patients are assessed and treatment priorities
established based on their injuries, vital signs, and
injury mechanisms
• ABCDEs of trauma care
• A Airway and c-spine protection
• B Breathing and ventilation
• C Circulation with hemorrhage control
• D Disability/Neurologic status
• E Exposure/Environmental control

27. DON’T GET DISTRACTED WITH UGLY
“INJURIES”

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

29. 3.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

30.  AIRWAY ASSESSMENT AND C-SIPNE
CONTROL
• Airway should be assessed for patency
• Is the patient able to communicate verbally?
• Inspect for any foreign bodies
• Examine for stridor, hoarseness, gurgling, pooled secretions
or blood
• Assume c-spine injury in patients with multisystem trauma
• THE MANTRA BEING”AIRWAY MANAGEMENT WITH
CERVICAL SPINE STABILISATION”

31. MILS- MANUAL IN LINE STABILISATION
• INDEX FINGERS IN THE
EXTERNAL AUDITORY
CANAL
• PALMS ON THE
PARIETAL BONE
• THUMBS ON THE FORE
HEAD
• REMAINING FINGERS
UNDER THE MASTOID
PROCESSES
• WITHOUT APPLYING
AXIAL TRACTION

32. PATIENT
CONSCIOUS
ORIENTED
FAILS TO RESPOND
APPROPRIATELY(DROWSY
OR UNCONSCIOUS)
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(PENET
RATING INJURY)
YES (VOCALISES
NORMALLY)
ASK TO TAKE DEEP BREATHS
ASSESS UPPER AIRWAY,
CHEST EXPANSION
SUPPLEMENTAL O2
CERVICAL COLLAR

33. • 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
• SURGICAL AIRWAY
• CAN’T INTUBATE
• DISTORTED ANATOMY
• IN FAILED INTUBATION – LMA AS BRIDGE

34. • ADVANCED AIRWAY TECNIQUES-
• FOB
• specialized laryngoscopes
• Bougies
• double lumen tubes
• Laryngeal injury-immediate tracheostomy
• At least 3 assistants required FOR INTUBATION-
• MILS
• cricoid pressure
• DRUGS

35. 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

36. BREATHING WITH SUPPLEMENTAL OXYGEN
• INSPECT:Equal chest rise, paradoxical chest
movements,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!!!!!

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

38. 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.

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

40. 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

41. IDENTIFY
• External hemorrhage
• Apply direct pressure
• Be aware of possible sources of
internal bleeding both from blunt
and penetrating trauma

43. Primary Survey - Circulation

44. MANAGEMENT OF CIRCULATION
• Control bleeding with direct
pressure
• Splint limb fractures
• Insert 2 large bore IV cannulas
in adults
• Send off blood-cross match,
coagulation screen,Hb,
hct,biochemistry,blood alcohol
level if req
• Intraosseous needle in children
up to 10 yrs.

45. • Fluid replacement: adults up to 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

46. DISABILITY AND NEUROLOGIC STATUS
• DISABILITY assessed by AVPU scale
• A. Alert i.e. Obeys commands
• V. vocalizes-inappropriate or incomprehensible
• P. Responds to pain
• U. Unresponsive
• NEUROLOGIC ASSESSMENT-GCS SCALE, pupil reaction to light,
limb movement
 Consider possible injuries-depressed skull fractures, SDH, SAH,
DAI, spinal injury
 Clearing the cervical spine-no spinal tenderness, normal conscious
state, normal neurological examination, no major distracting
injury,. Collar may be removed and no further investigation
required

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

48. Disability Interventions
• Spinal cord injury
• High dose steroids if within 8 hours
• ICP monitor- Neurosurgical consultation
• Elevated ICP
• Head of bed elevated
• Mannitol
• Hyperventilation
• Emergent decompression

49. E- Exposure
• You can’t treat what you don’t find!
• If you don’t look, you won’t see!
• Logroll the patient to examine patient’s back
• Maintain cervical spinal immobilization
• Palpate along thoracic and lumbar spine
• Minimum of 3 people, often more providers required
• Avoid hypothermia
• Apply warm blankets after removing clothes
• Hypothermia = Coagulopathy
• Increases risk of hemorrhage

50. Always Inspect the Back

51. Trauma Logroll
• One person = Cervical spine
• Two people = Roll main body
• One person = Inspect back and
palpate spine

52. 3.RESUSCITATION
• Protect/Secure airway & protect C-spine
• Breathing/Ventilation/Oxygenation
• Vigorous shock therapy
• At least 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

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

54. Apply appropriate
monitoring device

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

56. DIAGNOSTIC PROCEDURES

58. CASE STUDY
• 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

59. • 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
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.
INTUBATE WITH
MILS
ICTD- 5TH ICS

60. • X-RAY PELVIS- NAD
• FAST- COLLECTION IN ALL QUADRANTS
• OR NOTIFIED FOR URGENT LAPAROTOMY
• DISABILITY- GCS- 7/15,
• EXPOSURE PRIOR TO OR- RULE-OUT
HIDDEN INJURIES
• DAMAGE CONTROL LAPAROTOMY
• PATIENT SHIFTED TO ICU FOR
OBSERVATION AND FURTHER
MANAGEMENT.

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

62. 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

63. • HEAD
• Signs of skull base fracture
• Pupillary size
• Hemorrhages of
conjunctiva/fundi
• Visual acuity
• Penetrating injury
• Contact lens
• Dislocation of lens
• Ocular movement
• Posterior scalp laceration

64. • MAXILLOFACIAL
• Associated with airway obstruction or major bleeding
• Fracture
• No NG tube [performed oral route]

65. • NECK
• Cervical tenderness, subcutaneous emphysema
• Esophageal injury
• Tracheal/laryngeal injury
• Carotid injury (penetrating/blunt)

66. • CHEST
• Inspect
• Palpate
• Percuss
• Auscultate
• Obtain x-rays

67. • ABDOMEN
• Inspect
• Auscultate
• Palpate
• Percuss
• Reevaluate
• Special studies

68. • Musculoskeletal
• Contusion, deformity
• Pain
• Perfusion
• Peripheral neurovascular status
• X-ray

69. 6.ADJUNCTS TO SECONDARY SURVEY
• Special diagnostic tests as indicate
• CT
• Contrast x-ray studies
• Extremity x-ray
• Endoscopy
• Ultrasound

70. 7.DEFINITIVE CARE
• OR
• ICU
• Refer

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

72. 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 cause hypotension and
respiratory depression

73. TO SUMMARISE
• Organized team approach
• Priorities in management and resuscitation
• Rule out more serious injuries
• Through examination
• Frequent reassessment
• Monitoring

74. REFERENCE
• emedicine.medscape.com/article/434707-
• www.uptodate.com/contents/initial-management-of-
trauma-in-adults
• lifeinthefastlane.com › Education
• www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central
(PMC)
• www.trauma.org/archive/anaesthesia/initialassess.html